Marissa Gorhau
Avon By The Sea,NJ
Summary
With a proven track record at AIG Claim Services, I excel in disability and medical claims, blending fraud detection expertise with exceptional teamwork. My initiatives significantly enhanced processing efficiency and accuracy, demonstrating adaptability and a commitment to excellence in fast-paced environments. Detailed Adjuster with 33+ years of experience in corporate insurance claims. Strong command of claimant information intake processes, records documentation and fraudulent investigation protocols.
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Demonstrates analytical, communication, and teamwork skills, with proven ability to quickly adapt to new environments. Eager to contribute to team success and further develop professional skills. Brings positive attitude and commitment to continuous learning and growth.
Overview
26
26
years of professional experience
2
2
years of post-secondary education
1
1
Certification
Work History
Disability Claims Examiner
AIG Claim Services
11.2014 - Current
- Recommended process improvements that led to a reduction in processing errors and increased overall department efficiency.
- Contributed to team success by sharing knowledge, providing support, and assisting colleagues when needed.
- Evaluated and interpreted state and federal regulations to ensure compliance in the handling of all disability claims.
- Increased customer satisfaction by promptly addressing concerns or questions from both claimants and providers during the claims process.
- Reduced claim processing time with thorough review of medical records, interviews, and documentation.
- Participated in continuous training programs to stay current on industry trends, best practices, and regulatory changes impacting disability claims management.
- Conducted comprehensive investigations into each case to determine eligibility for benefits based on objective evidence and established criteria.
- Managed a high volume of cases while maintaining a strong attention to detail, resulting in timely and accurate decisions.
- Delivered unbiased decisions that adhered strictly to established policies while taking into consideration individual circumstances surrounding each case.
- Established credibility with claimants by demonstrating empathy, integrity, and professionalism throughout the claims process.
- Examined claims forms and other records to determine insurance coverage.
- Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
- Conducted day-to-day administrative tasks to maintain information files and process paperwork.
- Researched claims and incident information to deliver solutions and resolve problems.
- Analyzed information gathered by investigation and reported findings and recommendations.
- Identified suspicious losses and contacted manager for investigative assistance.
- Followed up on potentially fraudulent claims initiated by claims representatives.
- Maintained claims data in Luminx and eCSO systems.
- Verified accuracy of medical records to maintain accuracy of records database.
- Conducted regular audits of closed cases, identifying trends, and providing feedback for continuous improvement within the claims department.
- Improved claim processing efficiency by implementing new organizational methods and streamlining workflows.
- Assisted in developing departmental guidelines ensuring consistent application of industry standards and regulatory requirements across all cases.
- Conducted comprehensive interviews of claimants to gather facts and information.
- Reviewed police reports and medical treatment records to determine extent of liability.
- Reviewed questionable claims by conducting claimant interviews to correct omissions and errors.
- Determined liability outlined in coverage and assessed documentation such from police and healthcare providers to understand damages incurred.
- Maintained contact with claimants and providers to determine treatment status.
- Prepared medical documents for supervisors, managers or legal personnel.
Medical Claims Examiner
AIG Claim Services
02.1999 - Current
- Enhanced claim processing efficiency by conducting thorough investigations and maintaining accurate documentation.
- Provided exceptional customer service, addressing concerns from policyholders and answering inquiries related to their claims status.
- Improved interdepartmental communication by fostering a collaborative environment and sharing vital information regarding complex cases.
- Maintained compliance with industry regulations and company policies while evaluating medical claims for accuracy and legitimacy.
- Supported team members during periods of high workload, providing guidance on challenging cases or offering assistance when needed.
- Increased productivity by implementing efficient strategies for handling high volumes of medical claims daily.
- Reduced errors in claim submissions by meticulously reviewing patient information and verifying insurance eligibility.
- Developed expertise in specialized areas such as disability claims management or dental claims to better serve diverse client needs.
- Achieved excellent outcomes for both patients and healthcare providers by applying sound judgment in adjudicating complex medical claims.
- Collaborated with healthcare providers to obtain necessary medical records, ensuring timely and accurate claim adjudication.
- Kept up-to-date on company training sessions to continuously improve professional skills.
- Identified fraudulent activities by analyzing patterns, trends, and discrepancies in medical claims data.
- Implemented quality control measures to detect potential issues early on, preventing costly mistakes or delays in payment processing timeframes.
- Streamlined workflow for faster resolution of medical claims through effective prioritization and organization.
- Managed large volume of medical claims on daily basis.
- Identified and resolved discrepancies between patient information and claims data.
- Monitored and updated claims status in claims processing system.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Researched and resolved complex medical claims issues to support timely processing.
- Verified patient insurance coverage and benefits for medical claims.
- Paid or denied medical claims based upon established claims processing criteria.
- Evaluated medical claims for accuracy and completeness and researched missing data.
- Assessed medical claims for compliance with regulations and corrected discrepancies.
- Reviewed provider coding information to report services and verify correctness.
- Used administrative guidelines as resource or to answer questions when processing medical claims.
- Responded to correspondence from insurance companies.
- Followed up on denied claims to verify timely patient payment and resolution.
- Processed insurance payments and maintained accurate documentation of payments.
- Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
- Interviewed claimants and providers to correct errors or omissions and investigate questionable claims.
- Prepared medical documents for managers or legal personnel.
- Examined claims forms and other records to determine insurance coverage.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
- Conducted day-to-day administrative tasks to maintain information files and process paperwork.
- Researched claims and incident information to deliver solutions and resolve problems.
- Handled incoming calls from customers and providers about claims processes.
- Verified accuracy of medical records to maintain accuracy of records database.
- Maintained claims data in Luminx and eCSO systems.
- Followed up on potentially fraudulent claims initiated by claims representatives.
- Identified suspicious losses and contacted manager for investigative assistance.
- Determined liability outlined in coverage and assessed documentation such from police and healthcare providers to understand damages incurred.
- Reviewed questionable claims by conducting claimant and provider interviews to correct omissions and errors.
- Kept up-to-date on company sponsored training sessions and continuously improve professional skills.
Dental Claims Examiner
American General / AIG
02.2000 - 12.2014
- Achieved cost savings by identifying fraudulent or abusive billing patterns through meticulous analysis of claim data.
- Reduced payment delays with thorough investigation of discrepancies in submitted claims.
- Informed decision-making by analyzing historical claim data to identify trends that could impact future operations or business strategies.
- Ensured compliance with state regulations by keeping abreast of legislative changes impacting dental insurance policies and procedures.
- Maintained detailed records of all examined claims for accurate documentation purposes as well as easy reference during potential disputes or audits.
- Consistently met deadlines, ensuring timely processing of dental claims under high-pressure situations.
- Delivered excellent customer service by addressing patient inquiries regarding claim status, coverage details, and billing concerns in a timely manner.
- Facilitated dispute resolutions between providers and patients efficiently while maintaining a neutral stance during negotiations.
- Supported team members, sharing expertise in dental coding systems and insurance policies to improve overall performance.
- Enhanced claim processing efficiency by meticulously reviewing dental claims and verifying patient eligibility.
- Streamlined communication for better resolution by promptly addressing provider inquiries regarding claim status and policy interpretation.
- Contributed to departmental goals achievement through consistent participation in team meetings, brainstorming sessions, and collaboration on special projects as needed.
- Checked documentation for accuracy and validity on updated systems.
- Verified client information by analyzing existing evidence on file.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Generated, posted and attached information to claim files.
- Made contact with insurance carriers to discuss policies and individual patient benefits.
- Posted payments to accounts and maintained records.
- Calculated adjustments, premiums and refunds.
Education
Associate of Applied Science - Business
Ocean County College
Toms River, NJ 09.1990 - 05.1992
Skills
Medical terminology
Fraud Detection Skills
Appeal Review/Process
Disability claims process
Claims Evaluation
Adaptability
Disability Assessment Knowledge
Teamwork and Collaboration
Problem-Solving
Documentation proficiency
Claims Investigation
Customer service and support
Organizational Skills
Accomplishments
New Year State License Accident and Health Claims Processing.
Texas License Accident and Health Claims Processing with reciprocity to the following states: CT, DE, FL, GA, ID, KY, LA, ME, MS, NC, NH, NM, NV, NY, OK, OR, RI, SC, UT, VT, WA and WV.
Certification
- CT Casualty Adjuster
- CA All Lines
- DE Adjuster Casualty,Property
- FL Adjuster General Lines - All
- GA Adjuster - NonResident Adjuster - Casualty,Adjuster - Property
- ID Independent Adjuster Independent
- KY Independent Adjuster Property and Casualty
- LA Claims Adjuster Property and Casualty
- ME Adjuster Limited Home State
- MS Independent Adjuster Property and Casualty with Workers' Comp
- NC Adjuster Company/Independent Firm Adjuster, LOA Not Applicable
- NH Adjuster Property and Casualty Including Workers Compensation
- NM Independent Adjuster None
- NV Independent Adjuster Adjuster - Property and Casualty
- NY Independent Adjuster Adjusting-Accident and Health
- OK Adjuster Casualty, Property
- OR Adjuster General Lines
- RI Company/Independent Adjuster Property/Casualty
- SC Adjuster Casualty,Property
- TX Adjuster - Designated Home State Texas Adjuster - All Lines DHS TX
- UT NonResident Independent Adjuster Independent Adjuster Accident & Health,Independent Adjuster Property & Casualty
- VT Adjuster - Property and Casualty Casualty,Property
- WA Independent Adjuster Casualty, Property
- WV Independent Adjuster Property and Casualty
- WV Company Adjuster Property and Casualty
Languages
English
Native or Bilingual
Tagalog
Native or Bilingual
Timeline
Disability Claims Examiner
AIG Claim Services
11.2014 - Current
Dental Claims Examiner
American General / AIG
02.2000 - 12.2014
Medical Claims Examiner
AIG Claim Services
02.1999 - Current
Associate of Applied Science - Business
Ocean County College
09.1990 - 05.1992
- CT Casualty Adjuster
- CA All Lines
- DE Adjuster Casualty,Property
- FL Adjuster General Lines - All
- GA Adjuster - NonResident Adjuster - Casualty,Adjuster - Property
- ID Independent Adjuster Independent
- KY Independent Adjuster Property and Casualty
- LA Claims Adjuster Property and Casualty
- ME Adjuster Limited Home State
- MS Independent Adjuster Property and Casualty with Workers' Comp
- NC Adjuster Company/Independent Firm Adjuster, LOA Not Applicable
- NH Adjuster Property and Casualty Including Workers Compensation
- NM Independent Adjuster None
- NV Independent Adjuster Adjuster - Property and Casualty
- NY Independent Adjuster Adjusting-Accident and Health
- OK Adjuster Casualty, Property
- OR Adjuster General Lines
- RI Company/Independent Adjuster Property/Casualty
- SC Adjuster Casualty,Property
- TX Adjuster - Designated Home State Texas Adjuster - All Lines DHS TX
- UT NonResident Independent Adjuster Independent Adjuster Accident & Health,Independent Adjuster Property & Casualty
- VT Adjuster - Property and Casualty Casualty,Property
- WA Independent Adjuster Casualty, Property
- WV Independent Adjuster Property and Casualty
- WV Company Adjuster Property and Casualty
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