Javier Ponder
Lithia Springs,GA
Summary
Career Objective: To obtain a career position that will enhance present skills, while enabling myself opportunities for advancement with increasing responsibilities with the ability to be able to mentor and utilize the skills to aid in the success of other.
I am a dedicated expert in the field of Insurance, health, safety and risk with years of experience in different roles of insurance claims, specializing in Auto/TPL/GL, workers compensation, STD/FMLA, safety, mitigating losses, Return to work, Litigation, and identifying risk. I have over ten years of experience with claims handling, identifying risk, reducing loss, and mitigation while supporting various clients/organizations to ensure a safe, working environment. I know how to communicate professionally and connect on all levels with the ability to listen and show empathy when appropriate; navigate through multiple software applications, work independently and remain productive while promoting self-motivation and the ability to be a leader as well as an asset to the Team while still producing a high quality of performance.
Overview
17
17
years of professional experience
1
1
Certificate
Work History
Senior Disability Claims Examiner Lead
Sedgwick Claims Management
REMOTE
08.2021 - Current
- Process STD/FMLA Claims for one main client
- Manage Claim in whole from First Day of Disability to Return to work
- Request and read medical supporting documentation to make a timely decision to approve or deny benefits
- Adhere and follow all statutory guidelines.
- Approve any applicable federal and state LOA plans and benefits
- Notify employer of estimated Return to Work date and if any restrictions are applicable.
- Finalized std files for claim payment release.
- Reviewed and analyzed suspicious and potentially fraudulent claims.
- Built strong relationships with customers through positive attitude and attentive response.
- Conducted training and mentored team members to promote productivity, accuracy and commitment to friendly service.
- Demonstrated knowledge of company mission and goals and mentored employees in reaching objectives aligned with company core values.
- Coached team members in customer service techniques, providing feedback and encouragement toward reaching sales goals.
- Facilitated training for associates through daily coaching and regular performance appraisals.
CRC HR Manager Assistant III-contract
Amazon
Remote
07.2020 - 11.2020
- Point of Contact for all documentation regarding Leave of Absence for COVID-19 related illness
- Assess the medical documentation regarding COVID diagnosis to determine to approve Special Grant of Pay and LOA
- Oversaw legal compliance with federal, state and local laws and regulations in addition to compliance with company policies and procedures.
- Monitored and handled employee claims involving performance-based and harassment incidents.
- Recommended, initiated and finalized HR actions regarding faculty and staff position management, compensation, and employment postings, hiring proposals and new hire onboarding.
- Maintained company compliance with local, state and federal laws, in addition to established organizational standards.
Virtual Customer Service Representative
AAFES
11.2019 - 06.2020
- Receive Inbound calls to Assist our Military Members and their families with placing orders and reviewing Orders for Shopmyexchange.com
- Assist Service Members with their Military Star Credit card
Injury/Risk Counselor
Primo Water Corporation
Atlanta, GA
06.2017 - Current
- Coordinate Return to work for all injured associates and authorize assignments for modified/transitional work assignments for multi-states. (23 states)
- Report claim to TPA and work with them to investigate and determine compensability; work with attorney’s on litigation claims; explore subrogation; negotiate settlements; follow claim through closure and MMI of associate
- Improve quality of company's Workers Compensation claim handling practices and ensure that this quality of claim handling is consistent for all associates and ensure employees are receiving holistic/conservative treatment in accordance to State WC Laws
- Manage Leave of absence in conjunction with state and federal laws (FMLA)
- Interpret and understand medical and legal terminology
- Facilitate communications with frontline managers, TPA claims adjusters, Human Resources, associates and others involved in cases and safety
- Work with Safety Team to determine root cause and preventability
- Supports the finance department in the preparation of all audits and insurance renewals process as well as TPA vendor changes
- Use the latest techniques towards maintaining a safe, positive, and ethical environment, ensure Medical Panels are reviewed annually,
- Stay current with company’s policy/procedures, Federal Health and Safety regulations, and maintain and report all incidents to OSHA.
Claims Specialist Manager
Parallon/HCA Shared Services, Auto/TPL, VA
Atlanta, GA
02.2017 - 06.2017
- Supported claims in the Southeast Region- Georgia, Alabama, South and North Carolina, Florida
- Work insurance pools and contact insurance companies to resolve claims that are not paid in a timely manner
- Analyze and process claims by gathering information and investigating
- Review EOB’s, remits and payer correspondence in the course of performing account follow-up and escalate any identified issues to the appropriate area for review and response to expedite claim resolution
- Identify problem accounts and escalate as appropriate
- Maintain compliance with pool completion requirements
- Maintain required productivity and QA standards
- Document in the patient account record to identify actions taken on the account
- Work with patients and guarantors resolve payer requests and discrepancies to promptly resolve pending claims.
Senior Claims Specialist
Optum 360- United Healthcare- Contract
Atlanta, GA
01.2017 - 03.2017
- Perform billing/collection functions relevant to the Patient Financial Services area in a manner that consistently meets or exceeds a score of 95% in key performance criteria to be measured by Quality Assurance audits
- Maintain thorough and detailed knowledge of collection laws and third party payer claims processing- Tricare, VA, Medicare claims and ensures compliance with state laws regarding all cash processes as evident through cash collections
- Perform hospital billing and rebilling functions as appropriate and exhibits extensive knowledge of all bill forms and filing requirements
- Identify and resolve problems and make recommendations for process improvements that will benefit PFS
- Continually seek to understand and act upon customer needs, concerns and priorities
- Meet customer expectations and requirements and gain customer trust and respect
Workers Compensation Claims Admin Supervisor
Revclaims LLC
Atlanta, GA
08.2015 - 01.2017
- Work independently in a production environment to Transfer information from EPIC to Revshell Database; identify and add all potential insurances or TPL for Auto Claims
- For Workers Compensation claims inform injured workers of all treatment options
- Review and work Account from start to completion
- Supported claims in the state of GA only
- Build relationship for coordinated efforts with the injured, tpl, benefits providers, and insurance companies
- Work the onsite database requestor to perform any administrative request and coordinate case management
- Manage litigation/subrogation request
- Speak with Attorney to ensure timely claim resolution and payment
- Act as a liaison between the business/finance department, billers, third party payers, and Revclaims in resolving billing and reimbursement accuracy, managing denials and any appeals process throughout the life of the claim
- Work accounts of patients that has been in motor vehicle accidents to ensure account is timely and updated with any important documentation; identify any open liability/Medpay claims and benefits; TPL; ensure claims are properly processed and coded correctly; track and resolve underpayments
- Work accounts of employees that has been injured while being employed at Grady Memorial hospital premises
- Arrange care and Coordinate medical management, vendor referrals, and report and prepare any state filings
- Handle DOT claims promptly and efficiently.
Patient Intake Coordinator
Fresenius Medical Care
Atlanta, GA
02.2015 - 07.2015
- Supported claims in the Southeast Region- Georgia, Alabama, South and North Carolina, Florida
- Served as the primary contact for the initial administration of patient referral calls and communications regarding patient admissions to BU Clinics (chronic and acute) and home programs
- Coordinates the admission process from the initial request to the final authorization ensuring all aspects of patient confidentially are maintained at all times
- Interviews patient/patient representative to collect and obtain all important information such as medical records, insurance/billing information, and contact information
- Verifies insurance and entered proper coding
- Handle any denials and appeals from patients Insurance provider
- Schedules and coordinates patient’s appointment times and sends confirmation to the patient.
Patient Education Coordinator/ Utilization Management Representative
Anthem Inc
Atlanta, GA
11.2013 - 02.2015
- Educate various members about their benefits and preventative care services
- Identify members with HEDIS Gaps in care and educate them on having annual check –ups, ensuring AC1 testing as been completed, and etc
- Schedule and set up appointments for members
- Set up interview for assistance with Social services
- Called various hospitals to request prior authorization and pre-certs for service
- Assistant HCC with getting enrolled in the case management program
- Coding ICD codes/general coding and claims handling process-billing/collections of payment.
Lottery Analyst
Gtech Corporation
Atlanta, Ga
11.2012 - 10.2013
- Identified and resolved problems through root cause analysis and research.
- Validated results and performed quality assurance to assess accuracy of data.
- Applied knowledge of data modeling and statistical analysis to note trends and draw conclusions.
- Performed system analysis, documentation, testing, implementation and user support for platform transitions.
- Documented procedures and business processes and shared information with appropriate stakeholders.
Assessment Coordinator
Alere Healthcare
Atlanta, GA
01.2012 - 10.2012
- Work with various insurance companies to verify policies for Patients that wanted to enroll into the Prenatal Program
- Assessed patients and documented their medical histories
- Responsible assigning a nurse for primary care, case management, and medication management and HEDIS gaps in care prevention
- Evaluated patient care needs, prioritized treatment, and maintained patient flow
- Entered and processed Pre-certs and prior authorizations
- Benefits verification
Team Lead
Ryla Teleservices
Kennesaw, GA
06.2007 - 12.2011
- Managed high call volume with tact and professionalism
- Accurately documented, researched and resolved customer service issues
- Oversaw call center employees to ensure customer satisfaction goals were consistently met
- Conducted quality audits for all Customer Service Representatives to reduce resolution time and improve customer satisfaction rates
- Analyzed call volume and average call time to monitor Customer Service Representative performance and productivity
- Approve time and submit payroll adjustments.
Education
Bachelor of Science - Chemistry/business
Clark Atlanta University
Atlanta, GACertificate - AIC- Associate in Claims
Risk Institution
Remote12.2022
High School Diploma -
Banneker High School
College Park, GA05.2006
Skills
- Settlement Negotiation
- Communication skills-written, verbal and presentation; ability to effectively communicate, persuade and collaborate with team
- Strong knowledge of Operations and Superior organization and self- management skills
- Loyalty Building
- Administration and Reporting
- Performance Tracking and Evaluations
- Flexible & Adaptable
- Conflict Resolution
- Self-Motivated
- Customer Service
- Microsoft Office
- Good listening skills
- Decision Making
- Management Consultation
- Claims investigation and research
- Disability claims process
Certification
- CIE - Certified Insurance Examiner
Timeline
Senior Disability Claims Examiner Lead
Sedgwick Claims Management
08.2021 - Current
CRC HR Manager Assistant III-contract
Amazon
07.2020 - 11.2020
Virtual Customer Service Representative
AAFES
11.2019 - 06.2020
Injury/Risk Counselor
Primo Water Corporation
06.2017 - Current
Claims Specialist Manager
Parallon/HCA Shared Services, Auto/TPL, VA
02.2017 - 06.2017
Senior Claims Specialist
Optum 360- United Healthcare- Contract
01.2017 - 03.2017
Workers Compensation Claims Admin Supervisor
Revclaims LLC
08.2015 - 01.2017
Patient Intake Coordinator
Fresenius Medical Care
02.2015 - 07.2015
Patient Education Coordinator/ Utilization Management Representative
Anthem Inc
11.2013 - 02.2015
Lottery Analyst
Gtech Corporation
11.2012 - 10.2013
Assessment Coordinator
Alere Healthcare
01.2012 - 10.2012
Team Lead
Ryla Teleservices
06.2007 - 12.2011
Bachelor of Science - Chemistry/business
Clark Atlanta University
Certificate - AIC- Associate in Claims
Risk Institution
High School Diploma -
Banneker High School
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