Summary
Overview
Work History
Education
Skills
Timeline
Generic

M. Rene' Brown

Gretna,LA

Summary

Motivated Claims Adjuster experienced in personal and occupational injuries resulting in loss, damage, or impairment to normal bodily functions. Process, adjudicate, and negotiate amicable resolutions with emphasis on being fair, expedient, and without partiality in applying the best approach that's beneficial to all parties involved. Skilled in investigating and analyzing liability concerning work and personal healthcare related concerns. Excellent communication skills demonstrated to freeze fears and warm thoughts through acts of care and compassion.

Overview

12
12
years of professional experience

Work History

Workman Compensation Adjuster

AIG Insurance
05.2006 - 04.2009
  • Received and investigated Workman Compensation claims along with written or recorded statements to determine compensability, and/or third party subrogation.
  • Gathered information from employer and/or witnesses surrounding details of injury in determining if it occurred out or within course and scope of employment.
  • Coordinated appointments with medical providers in diagnosing, determining, and treating disability within their practice of expertise, and/or consulting with physicians in specialty areas like surgery.
  • Corroborated with medical staff in determining level of disability and its percentage (temporary/total/permanent), work restrictions, and/or maximum medical improvement (MMI).
  • Authorized and monitored medical treatment in consultation with physicians by requesting and reviewing medical records, monitored physician compliance with labor laws, reviewed medical bills for contract adherence, interpreted and applied medical terminology in determining appropriate course of action, and authorized surveillance when claimant's complaints did not align with medical assessment.
  • Corresponded with Claimant or Attorneys in person, via telephone, or by written correspondence to gather additional information, explain benefits, or legal rights under Workman Compensation Laws.
  • Established and maintained adequate reserves for medical, indemnity, and expenses on claims within authorized levels to reflect potential value of claim to allow payment of medical bills and payment to Claimant for lost time out of work past waiting period, or for possible settlement of claim.
  • Overall, managed more than 30 telephone calls, email inquiries and faxes combined daily while meeting and exceeding claim production.

Medical Claims Analyst

F.A.Richard And Associates/FARA
08.2003 - 04.2006
  • Provided excellent customer service for Self-Funded, Managed Care, and Indemnity health insurance plans.
  • Reviewed and adjudicated health related claims based on Schedule of Benefits/policy provisions and established guidelines.
  • Accurately completed investigations of medical conditions, accidents, medical necessity appropriateness, eligibility, and coordination of benefits to ensure reimbursement payments were accurate according to repricing schedules, Coordination of Benefits, and Medicare reimbursement.
  • Coordinated Benefits with third party payers and identified discrepancies in billing.
  • Maintained company production requirement of claims and ensured accuracy with 99.9% precision rate by meticulously reviewing medical records, Coordination of Benefits, and all supporting documentation in support of payment.
  • Reviewed all medical/surgical bills to ensure diagnosis and procedure codes were accurately noted along with proper modifiers if necessary to identify complexity of procedure to support billing.
  • Secured necessary documentation or letters of medical necessities (LOMN) to support appropriate payments requested and/or authorized.
  • Proficient in medical industry knowledge of terminology, healthcare, and insurance.

Medical Claims Analyst

Tulane Preferred Health Plan
05.1997 - 01.2001
  • Reviewed medical claims for payment according to insurance policy standards and guidelines for Health Maintenance Organization (HMO).
  • Proficient in industry knowledge of medical terminology, medical insurance, billing process, and ICD-10 and CPT codes.
  • Provided exceptional customer service for Health Maintenance Organization (HMO) as primary payor or secondary payor through coordination of benefits as presented on Explanation of Benefits (EOB)
  • Reviewed, validated, and adjudicated medical, dental, or Durable Medical Equipment (DME) claims for payment and /or coordinated benefits between Medicaid, and/or other Commercial insurance carriers.
  • Identified and researched denial reasons to determine correct action needed to support appeal's process.
  • Proficient understanding of UB/1500 medical claim forms.
  • Intermediate knowledge of Microsoft Office (Word, Excel, Powerpoint) skills.

Education

Master of Science - Business Administration/Healthcare Management

University of Phoenix
Metairie, LA
05.2005

Certification in Pharmaceutical Sales - Certification of Pharmaceutical Sales

National Pharmaceutical Sales Representative
Dallas, TX
05.2005

Bachelor of Science - Healthcare Services

University of Phoenix
Metairie, LA
08.2003

Skills

  • Claims Investigation
  • Technical knowledge
  • Insurance Policy Interpretation of coverage
  • Manage litigation of Occupational injuries
  • Medical/Occupational Insurance knowledge
  • Claims Processing/Adjudication
  • Critical Thinking
  • Decision-Making
  • Active Listening
  • Computer Skills
  • Claims Evaluation
  • Effective Communicator
  • Settlement Negotiations
  • Denied claims identification

Timeline

Workman Compensation Adjuster

AIG Insurance
05.2006 - 04.2009

Medical Claims Analyst

F.A.Richard And Associates/FARA
08.2003 - 04.2006

Medical Claims Analyst

Tulane Preferred Health Plan
05.1997 - 01.2001

Master of Science - Business Administration/Healthcare Management

University of Phoenix

Certification in Pharmaceutical Sales - Certification of Pharmaceutical Sales

National Pharmaceutical Sales Representative

Bachelor of Science - Healthcare Services

University of Phoenix

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M. Rene' Brown