Meghan Mikell

• Reviewed police reports pertaining to the accident
• Reviewed medical records for injuries sustained on the date of loss
• Established/determined liability based on police report and facts of loss
• Researched coverage based on the insured's policy
• Ordered and requested policies and declaration pages of coverage from underwriting
• Interviewed the insured and took recorded statements to obtain facts of loss
• Responded promptly to customer inquiries regarding claim status or other issues.
• Sent out correspondence to attorney firms requesting medical bills and records
• Evaluated and processed bodily injury claims according to company guidelines
• Reviewed medical bills for accuracy and appropriateness of services rendered.
• Calculated loss wages
• Analyzed physician's reports, hospital records, laboratory results, operative reports, diagnostic tests. to assess medical necessity of services rendered.
• Provided settlement offers based on the findings of the evaluation
• Verified uninsured/underinsured motorist coverage
• Assessed and conducted negotiations within authority limits to settle claims.
• Corresponded daily with attorneys, case managers, other insurance adjusters.
• Assigned claim files to defense attorneys for new suit litigation
• Reviewed/verified diagnosis codes for specific treatment
• Evaluated medical records/reports from medical providers for specific injury details
• Calculated and accessed pain and suffering amounts based on severity of injuries
• Maintained knowledge of policies and procedures and insurance coverage benefit levels, eligibility systems and verification processes.
• Planned and conducted investigations of claims to confirm coverage and compensability.
• Drafted coverage denial letters
• Made outbound calls to attorneys and the name insured to discuss settlement
• Corresponded with internal departments to obtain complex injury diagnosis for future treatment and/or surgical procedures calculated wage loss
• Processed a high volume of claims on a daily basis using established time frames.

• Documented and communicated claim activity to clients.
• Assessed damage to exterior and interior of homes, structures on the property as well as personal property.
• Calculated settlement amounts and issued payments Provided quality customer service to assigned, insured and claimants throughout claims process to deliver timely service to customers.
• Created or updated records with new files or information.
• Verified details with policyholders and requested additional information. Assessed policy coverage and pulled contracts for review.
• Detailed coverage, liability and reasons for denial of claims to policyholders
• Processed claims from end to end
• Provided resolutions to claimants in regard to wind, hail, water roof leak damage
• Sent resolution/settlement letters pertaining to costs of repairs
• Obtained necessary information to complete proper evaluation of property damage claims.
• Managed caseload of 15-25 claims each day.
• Submitted claims and estimate re-inspections at the request of the member.
• Reviewed data to verify validity of claims and determine case management actions.
• Directed calls to other internal departments on an as needed basis

• Answered phones from automated call distribution systems.
• Coordinated scheduling between claimants and medical facilities throughout the U.S
• Reviewed medical records at claimants request to ensure documentation was downloaded within Veteran Affairs systems
• Triaged daily download of referrals and ensured appropriate worksheets are assigned to corresponding conditions as identified by Veteran's Administration
• Verified appropriate CPT and Clinical codes that are assigned to each case
• Communicated directly with claimants and providers
• Obtained medical history for specific conditions related to military service connection
• Determined appropriate examinations, tests and specialists required for each case
• Scheduled appointments for examinees including follow-up and rescheduled appointments
• Was responsible for providing claim status and gathered supporting documents to submit appeals.
• Ensured all examinees and providers receive necessary documentation
• Confirmed consultative reports and diagnostic test results are received in a timely manner
• Reviewed and researched insurance claims to determine possible payment source(s).
• Contacted various sources including insurance professionals, patients, and other parties to verity relevant data.
• Coordinated with payors to ensure appropriate filing guidelines are met for reimbursement.
• Requested appropriate information, both verbally and written, from appropriate parties to ensure proper claim disposition.
• Maintained and updated payors on denied claims.
• Ensured that appropriate billing guidelines and standards are met based on payor and/or State.
• Performed persistent follow up on unresolved claims
• Verified patient eligibility for medical claims and determined benefit coverage.

Worked in various clinics within Audie L. Murphy, clinics include but not limited to:

⦁ Dermatology, Cardiology, Psychiatry, Pulmonary/Respiratory etc.
⦁ Utilized Vista, CPRS (Computerized Patient Record System) and Vetlink
⦁ Printed and mailed future appointment letters to patients in a timely manner
⦁ Checked patients in and out of their scheduled appointment through the clinic kiosk (Vetlink)
⦁ Updated patients insurance through ICB (Insurance Capture Buffer)
⦁ Scheduled various testing for a variety of physicians and/or clinics, scheduled based on the veterans availability
⦁ Scheduled appointments for veterans to seek outside care through the Veteran Choice Program
⦁ Ordered labs per providers request
⦁ Modified appointments in Vista South Texas (DOS based program)
⦁ Worked with nurses and providers to provide excellent care for the Veterans
⦁ Contacted providers per request of the patient to fill prescriptions and obtain referrals for outside care

• Scheduled approximately 25-40 appointments daily for various departments.
• Educated patients about medications, scheduled procedures and physician's instructions.

As a Grievance and Appeals Coordinator my responsibilities included but not limited to:

• Drafted correspondence and documentation and submitted all materials to appropriate parties.
• Coordinated with multiple departments regarding responsive documents and document retention.
• Responded quickly to client calls and inquiries, asking open-ended questions to deliver applicable information.
• Maintained files on individual appeals and grievances.
• Prepared response letters on coverage determinations, member and provider complaints.
• Analyzed and resolved written and verbal communication grievances, authorization appeals and provide resolution of formal grievances from members.
• Provided grievance resolutions to members regarding coverage determinations on prescriptions that may be covered by the plan sponsor, formulary exceptions on non formulary drugs and tier exceptions to lower the members cost share between the member and the plan.

As a Medicare Enrollment/Eligibility Specialist my responsibilities included but not limited to:

• Received paper and online applications to process daily.
• Date stamped applications and miscellaneous mail.
• Reviewed applications for completeness of CMS (Centers of Medicare and Medicaid Services required information.
• Utilized Centers of Medicare and Medicaid systems.
• Verified member's effective dates for Part A and B of Medicare.
• Verified election periods in which the member can enroll in coverage for the Medicare Advantage Plan the company serviced.
• Verified Accuracy of data entered in systems.
• Identified missing elements and reviewed duplicate submissions of applications.
• Ensured that all enrollment & disenrollment requests were processed according to CMS requirements.
• Faxed, copied and scanned important documents.
• Contacted customers for missing information to ensure complete applications and proper documentation.
• Updated demographic information.
• Performed careful reviews of applicant data to ascertain compliance with eligibility criteria for economic assistance within the enrollees plan.
• Inputted all communication with applicants into computer system to facilitate future clarification and knowledgeable support.
• Learned new tasks when needed to support office needs.
• Worked closely with team members to deliver project requirements, develop solutions and meet deadlines.
• Providing feedback to enhance future performance.

As a Verification coordinator my responsibilities included but not limited to:

• Verified insurance for all insurance billed for Durable Medical Equipment (Medicare, Medicaid and private insurance).
• Continuously monitored and educated staff regarding new contracted insurance companies and their benefits/requirements.
  
• Followed pre-certification requirements for Timely approval.
• Provided correct diagnosis and procedure codes to bill insurance companies for patients.
• Obtained correct billing information and plan changes for each insurance group.
• Audited insurance verification completeness and researched plan errors in patient's files.
• Collaborated with internal department in meetings to implement accurate insurance payouts.
• Corresponded with doctor offices and all insurance groups about patients chart notes and diagnosis information.
• Performed accurate insurance verifications and maintenance of patient's files.
• Executed and completed assignments in a timely manner
  Adhered to company, Medicare and private insurance.
• Followed HIPAA and Medicare guidelines and regulations.
• Provided diagnosis and procedure codes to bill insurance companies on behalf of the patient.
• Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.
• Retained strong medical terminology understanding in effort to better comprehend procedures.
• Ensured that all patient and insurance data was updated regularly and carefully inputted into the company's computer system.