Kathy Busch

• Ordered information to complete files.
• Finalized files for insurance claim payment release.
• Consulted police and hospital records when needed.
• Used systems to program, set up functions and enter data for claims.
• Corrected codes to properly classify claims.
• Investigated properties to determine extent of damage and estimate repair costs.
• Investigated and processed insurance claims for policyholders.
• Researched claims and incident information to deliver solutions and resolve problems.
• Handled complaints and grievances using negotiating and problem-solving skills.
• Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
• Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
• Analyzed information gathered by investigation and reported findings and recommendations.
• Evaluated original investigation reports and documents to resolve secondary concerns.
• Verified accuracy of records to maintain accuracy of records database.
• Followed up with insured individuals regarding premium and deductibles payments.
• Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
• Directed claims negotiations within allowable limit of and supported successful litigations for advanced issues.
• Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
• Resolved complex, severe exposure claims using high service oriented file handling.
• Identified suspicious losses and contacted manager for investigative assistance.
• Followed up on potentially fraudulent claims initiated by claims representatives.
• Maintained claims data in systems.
• Examined claims forms and other records to determine insurance coverage.

· Provide operational support for assigned ESI Markets (Commercial, Medicare, Health Plan, etc.) for going plan changes, new implementations, and renewal activity.

· Review, analyze and verify intent of assigned benefit set-ups as they relate to products and programs. Identify and for customization to support client benefit requirements; attend client calls/meetings as needed; attend internal validation meetings; run customized and scheduled reports, manage performance guarantee tracking and report distribution for internal/external clients as requested.

· Adhere to all organizational Job Aides and Compliance standards; provide subject matter input as it relates to checklists and Job Aides

· Assist with operation input related to new product development, identification, research, and resolution of operational issues, offshore and contingent employee resources.

· Comply with ESI document and retention requirements.