Melissa Cook
Summary
Results-driven claims professional with a strong focus on precision and efficiency in claims evaluation and resolution. Demonstrated success in managing high caseloads and settling claims accurately, while adhering to company standards. Recognized for exceptional collaboration skills, fostering strong relationships with team members and adapting to changing needs. Committed to delivering reliable performance and consistently achieving positive outcomes.
Overview
24
24
years of professional experience
Work History
PIP Medical Adjuster
CURE AUTO INSURANCE
11.2023 - Current
- Handle NJ and PA medical claims
- Evaluated claims promptly and accurately to determine coverage
- Conducted thorough investigations into circumstances surrounding each claim through recorded statements
- Maintained detailed and organized claim files, documenting all relevant information, correspondence, and decisions made throughout the claim process
- Established and maintained the proper reserve for the exposure
- Provide exceptional customer service to insured's, claimant's, attorneys and medical providers, addressing inquiries and concerns in a timely and professional manner
- Ensure compliance with insurance regulations, company policies, and industry standards in all aspects of claim handling
- Collaborate with internal teams, including underwriters, legal counsel, nurse case manager, and other claims professionals, to resolve complex claim and mitigate risk effectively
- Identify opportunities for process improvement and contribute to the development of best practices within the claims department
- Identify potential fraud indicators and subrogation opportunities throughout the life cycle of the claim
- Provide backup assistance and coverage to team members when necessary
PIP Medical Adjuster
PLYMOUTH ROCK ASSURANCE
06.2022 - 11.2023
- Handled NJ, PA and motorcycle medical claims
- Received assigned claims, verified medical coverage, confirmed eligibility
- Completed detailed thorough claim investigation through telephone with insured's, attorneys, medical providers to obtain information relevant to the claim
- Analyzed information obtained through investigation in order to evaluate the claim, determined PIP eligibility and determined the extent of the injuries and claim exposure
- Established and maintained the proper reserve for the exposure
- Addressed incoming calls from insured's, attorneys, medical providers and billing companies
- Documented claim files and maintained a diary system for reporting and claim follow up
- Treated claims in accordance with Plymouth Rock's Decision Point Review Plan
- Maintains list of contact information for employees
- Assigned medical case managers or other experts to a case when appropriate and arranged for independent medical examinations when necessary to determine medical necessity and causal relationship of treatment
Administrative Claims Specialist
PLYMOUTH ROCK ASSURANCE
08.2021 - 06.2022
- Primary call center contact for Provider Service Unit- direct phone support for medical providers and billing companies regarding PIP medical claims
- Addresses a high volume of phone inquiries regarding medical bill and treatment statuses on an everyday basis
- Since month of hire has achieved 100% accuracy in bill entry, payment generation
- Since month of hire has answered 6265 calls with average hold time of 68 seconds and transfer rate of 3.7% (goal is under 10%)
- Individual production for December 2021 was 125.6% (January 2022 data not available yet)
- Perform data entry functions such as medical bill entry and payment generation using multiple software applications
- Participate in proactive team efforts to achieve departmental and company goals
- Determines coverage for PSU when needed
- Maintains list of contact information for employees
- Back up for priority interest payments
Account Clerk
MIDDLESEX COUNTY – DEPARTMENT OFFICE OF AGING & DISABLED SERVICES
01.2019 - 06.2022
- Established and amended county budgets for all Office Grants
- Created and modified all State Office grants (Area Plan Contract, Respite, PASP and SHIP)
- Responsible for quarterly State reports for 4 grants
- Created and revised budgets as needed for approximately 65 programs
- Worked with auditors on a bi-annual basis to reconcile grantee reporting
- Maintained organized and accurate records and file
- Input resolutions into Minute Traq for review by Board of County Commissioners
- Reviewed RFP's for grantee applications and submit feedback to County Legal Counsel
- Handle all OPRA requests for department
Special Assignment
MIDDLESEX COUNTY – COVID CALL CENTER
01.2021 - 08.2021
- Primary call center contact for homebound Middlesex County Residents to schedule a COVID 19 vaccine
- Directly contact over 300 county residents to discuss and coordinate homebound vaccine eligibility
- Work directly with IT to create vaccine appointments in Pro Portal
- Creates and maintains an up-to-date database for all eligible homebound vaccine recipients
- Coordinates with nursing team to plan and logistically map out schedules for COVID 19 homebound vaccines
- Answer calls and provide accurate and detailed information on how to register and/or schedule COVID 19 vaccine
- Wrote and established Middlesex County COVID 19 Resource Guide
- Train call center staff on web based virtual contact center
- Log number of daily calls answered
- Contacted county residents to provide COVID 19 test results
- Reconcile overtime hours submitted by call center agents to payroll reports
HVAC Install Coordinator
GOLD MEDAL SERVICES
11.2016 - 12.2018
- Worked closely with the lead installer and installation manager to ensure the team completes jobs on time and under budget, helped to achieve the company's financial goals
- Professionally answered the phone in a polite, friendly matter
- Called customers to set up equipment installations
- Scheduled and dispatched jobs for the installers
- Know how to establish customer rapport to ensure highest level of satisfaction
- Made sure all equipment is ordered and ready for each job, adhering to quality checklist
- Collected deposit and final payment due when installation is complete
- Complete and file all permits for each specific job
- File, log, and track all state and manufacturer rebates
Office Manager
Expaticore Services
06.2013 - 11.2016
Office Manager
BFS Group
08.2004 - 06.2013
Senior Mutual Fund Accountant
State Street Corporation
10.2001 - 07.2004
Operations Assistant
Northwestern Mutual Financial Network (Stone Agency)
06.2000 - 09.2001
Education
Bachelor of Science - Finance
RIDER UNIVERSITY
Lawrenceville, NJ01.2000
Skills
- MS Office (Excel, PowerPoint, Word)
- Morningstar Principia Pro
- Bloomberg Terminals
- PAM
- Basis Point
- Freedom
- Claims Pro
- Mitchell
- Guidewire
- Claims investigation
- HIPAA compliance awareness
- Effective communication
- ICD-10 coding
- Continuous learning mindset
- Decision-making confidence
- Problem solving prowess
- Strong analytical skills
- Time management mastery
- Critical thinking aptitude
- Data entry efficiency
- Conflict resolution techniques
- CPT coding
- Insurance regulations compliance
- Claims analysis expertise
- Medical terminology proficiency
- Medical record review
- Insurance claims processing
- HIPAA
- Thorough claims reviews
- Medical terminology
- Critical Decision-making
- ICD codes
- Reliability
Timeline
PIP Medical Adjuster
CURE AUTO INSURANCE
11.2023 - Current
PIP Medical Adjuster
PLYMOUTH ROCK ASSURANCE
06.2022 - 11.2023
Administrative Claims Specialist
PLYMOUTH ROCK ASSURANCE
08.2021 - 06.2022
Special Assignment
MIDDLESEX COUNTY – COVID CALL CENTER
01.2021 - 08.2021
Account Clerk
MIDDLESEX COUNTY – DEPARTMENT OFFICE OF AGING & DISABLED SERVICES
01.2019 - 06.2022
HVAC Install Coordinator
GOLD MEDAL SERVICES
11.2016 - 12.2018
Office Manager
Expaticore Services
06.2013 - 11.2016
Office Manager
BFS Group
08.2004 - 06.2013
Senior Mutual Fund Accountant
State Street Corporation
10.2001 - 07.2004
Operations Assistant
Northwestern Mutual Financial Network (Stone Agency)
06.2000 - 09.2001
Bachelor of Science - Finance
RIDER UNIVERSITY
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