Maressa Prah

As a Claims Professional who is specialized in potential Fraud, Waste, and Abuse cases I have the following responsibilities:

• Meticulously handle the eligibility process and documentation during initial, reassessment, and appeal reviews.
• Analyze and document all information gathered, which can include but is not limited to medical records, physician questionnaires, surveillance, UDC reports, IME reports, and outreaches to physicians/ providers for further clarifications
• Partnering with our care management team to ensure we are making accurate and precise decisions based on our findings within the file.
• In addition to eligibility analysis, I also maintain a company/ client relationship with our vendors/ TPA. This partnership allows open discussions daily on case management, documented findings, proposals, and reporting the overall activity within each case.

This is role is designated to work in specialty products, complex claims, and escalations with very specific requirements.

• Responsibilities;
• Service customer inquiries via incoming/ outgoing phone calls and written correspondence,
• Process transactions; including address changes, payments, case related changes and related correspondence.
• Diffuse escalated situations through analyzing, partnering, and resolving complex customer issues.

• Fraud roles responsibilities: monitor and maintain phone queues, case work, internal referral queues and to identify any potential suspicious activity such as account take over, fraud, and theft.
• Within this role you speak directly with authorized personal/ policy holders, and/or tipsters to better understand the activity on the account. You must be able to actively listen and document a full account of the provided information in order to refer this information to the SIU team to further investigate.

• Senior Claims Representative involved managing all aspects of the claim including claim management, direct client contact, and all documentation both internal and externally to clients.
• You are the primary analyst for each case assigned. You speak directly with the insured or parties involved to better their understanding with all processes and handling of the claim such as; financial information, document any case changes, and to educate the interested parties on any contract concerns.
• Within this role I was able to pursue several of my personal goals which include new hire trainings, mentoring, lead SCR rotations, and point of contact for my fellow colleges with any questions on processes.

Long-Term Care Claims as a customer service representative-

• In this role I obtained training on all contracts/ products with first call resolution knowledge, these calls enable a representative to be able to explain in depth payments, plans of care, reassessment processes and time frames. While taking these calls you gain valuable client relation knowledge during a challenging time in our customers lives.
• The calls include the following; personal health, financial information, and case management.
• The responsibilities are to deliver accurate and exact information to the authorized clients while maintaining brief and descriptive documentation in the file.

• I was employed as a part-time/seasonal employee taking inbound calls for in-store retail associates placing orders over the phone for the customer in store
• There is an additional responsibility for checking inventory to pull these items and recording all the clients billing/ shipping information to place the order
• Also I have placed out-bound calls regarding items our customers had ordered that had become 'short shipped', which meant the item/ items had be over ordered and our client would not be able to receive the item, the client had to be contacted to inform them they would not be charged for these items and try up sell an alternate item in place of the original item for around the same price range.

• My position as a customer service represented for the National Guard
• Making out-bound calls to people across the United States who request more information about the National Guard
• Collecting information on the client such as background information, telephone numbers, email address, home address, etc
• To help connect them to a recruiter to help further their knowledge, making upwards of two hundred to three-hundred fifty calls a day based on our number of clients logged that day
• The following campaign was for the Atlantic Journal Constitution helping in-bound callers file complaints or requests
• I Placed out-bound retention sales calls to get our subscribers to try to resubscribe based on their reason for declining the paper and asking if they would like a lower rate, delivery problem fixed, etc.