Linda Gottschall
CT
Summary
- Developed strong analytical and organizational skills in fast-paced, detail-oriented environment, seeking to transition into new field. Expertise in managing complex information and resolving issues efficiently. Committed to leveraging transferable skills to drive success in new role.
- Accomplished healthcare professional with a proven track record in enhancing patient care and reducing costs through effective medical reviews and utilization of resources. Skilled in medical record review and customer communication, adept at liaising between clients and providers. Excelled in streamlining operations and improving service delivery by leveraging Microsoft Office expertise.
Overview
30
30
years of professional experience
Work History
Claims Administrator
Sensible Benefit Solutions
04.2006 - 05.2024
- Counseled clients regarding their supplemental insurance benefits and coverage.
- Acted as a liaison between corporate headquarters and policy holder's to resolve claim processing issues and insure customer service.
- Independently managed and ran a small office and maintained its day to day operations.
- Obtained, reviewed and submitted medical records and clinical documentation for claim payment.
- Confirmed that the documentation forwarded to headquarters met state and federal guidelines.
- Utilized computer programs such as Microsoft Office, Outlook, Word and Excel.
- Communicated with clients telephonically, in person and via email.
Quality Insurance & Utilization Review Nurse
Interim HealthCare
09.2002 - 04.2004
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Analyzed adverse outcome reports to identify areas requiring improvement.
- Assisted with Medicare, State and Joint Commission audits.
- Analyzed nursing and therapy documentation to apply appropriate diagnosis coding to support Medicare reimbursement.
Claim Review Nurse
Cigna
06.1999 - 08.2002
- Reviewed medical records to determine medical necessity for claim payment,
- Reviewed provider billing for proper diagnosis and procedure coding to insure accurate reimbursement.
- Operated as a liaison between the claims office, Medical Director and Case management,
- Participated as a member of the Quality Assurance team was instrumental in developing policy and procedures.
Care Manager
United Healthcare
11.1994 - 06.1999
- Performed medical necessity reviews on hospital admissions, surgical procedures, home care, psychiatric and rehabilitation services.
- Coordinated care with the insured, family, physicians and facilities to insure patient medical needs were met in the most cost effective setting.
Education
Bachelor of Science - Human Development And Family Relations
University of Connecticut
Torrington, CT05-2000
Registered Nurse Diploma - Nursing
Saint Francis Hospital School of Nursing
Hartford, CT06-1986
Skills
- Customer communication
- Medical record review
- Liaison between clients and providers
- Maintain office
- Microsoft office
Timeline
Claims Administrator
Sensible Benefit Solutions
04.2006 - 05.2024
Quality Insurance & Utilization Review Nurse
Interim HealthCare
09.2002 - 04.2004
Claim Review Nurse
Cigna
06.1999 - 08.2002
Care Manager
United Healthcare
11.1994 - 06.1999
Bachelor of Science - Human Development And Family Relations
University of Connecticut
Registered Nurse Diploma - Nursing
Saint Francis Hospital School of Nursing
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