Patricia Clay
FL
Summary
LTD/STD Examiner with over 15 years of experience. Ready to help team achieve company goals. To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Senior Lead Analyst
DOL Doctors Of Tampa Bay
01.2022 - Current
- Manages LTD/STD Case Management and Claims submission
- Perform audit reviews of staff
- Review all medical documentation and confirm policy coverage and acknowledgement of the claim
- Determines validity and compensability of the claim by investigating and gathering information regarding the claim and filing necessary documentation with state agencies
- Establishes reserves and authorizes payments within reserving authority limits
- Develops and manages well documented action plans with the case manager and outcomes manager to reduce overall cost of the claim
- Coordinates early return-to-work efforts with the appropriate parties
- Manages subrogation and litigation of claim as it applies
- Reports claims to the excess carrier when applicable
- Communicates claim status with the claimant and examiner
- Adheres to client and carrier guidelines and participates in claims review as needed
- Develops and maintains professional customer relationships
- Complies with rules and regulations of applicable state
- Additional projects and duties as assigned
- Negotiate on out of network payment for service
- Account reconciliation
- Follow social media ads and reviews and appointments
- Plans and conducts investigations of claims (including such activities as interviewing insureds, witnesses and claimants, collecting and evaluating appropriate documentation and securing evidence and protecting the chain-of-custody) to analyze and confirm coverage and to determine liability, compensability and damages; determines need for, and engages independent adjusters, cause and origin experts and independent medical examiners
- Refers to claim to subrogation group or Special Investigations Unit as appropriate
- Assesses policy coverage for submitted claims and notifies the insured of any issues; determines and establishes reserve requirements, adjusting reserves, as necessary, during the processing of the claim
- Assesses actual damages associated with claims and conducts negotiations, within assigned authority limits, to settle claims
- Coordinates the litigation activities associated with assigned claims to ensure a timely and cost-effective resolution; attends trials as a representative of the company
- Acts as senior technical professional on team, assisting team members with escalated issues
- Mentors and trains new team members
- Participates in Quality Review process.
- Collaborated with cross-functional teams to implement data-driven solutions, driving business growth and profitability.
- Enhanced claim processing efficiency by meticulously reviewing medical records and identifying relevant information.
- Reduced the number of pending claims through diligent follow-ups and thorough case management.
- Maintained a high level of accuracy in data entry, ensuring correct claimant information and benefit calculations.
- Conducted comprehensive research to stay current on industry regulations and compliance requirements for accurate claim processing.
- Streamlined workflow processes by implementing organizational strategies, leading to expedited claim resolutions.
- Resolved disputes regarding benefit eligibility efficiently by providing clear explanations based on policy guidelines and regulations.
- Demonstrated strong attention to detail when interpreting policy documents, ensuring accurate application of terms to each case under review.
- Prevented fraudulent activity by conducting thorough investigations into suspicious claims and reporting findings accordingly.
- Monitored ongoing cases closely, adjusting benefits as needed based on changes in medical conditions or employment status of claimants.
- Evaluated, investigated and negotiated settlements on new and pending claims to determine liability.
- Delivered exceptional results under tight deadlines, consistently meeting or exceeding performance targets set by management.
- Managed claims, subrogation, liability reserve setting, negotiating and liability litigation support.
- Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Conducted day-to-day administrative tasks to maintain information files and process paperwork.
- Analyzed information gathered by investigation and report findings and recommendations.
- Conducted comprehensive interviews of witnesses and claimants to gather facts and information.
- Identified and forwarded claims to specialized internal and external resources in areas such as medical review, investigations, tender of claim, claim subrogation or physical damage experts.
Senior Adjuster - Remote
Conduent
10.2018 - 01.2022
- Make prompt contact with carrier client policyholders upon receipt of claim assignment
- Review coverage and document all communications with policyholders within carrier claim system
- Claim investigation, coverage determination, damage assessment and claim settlement
- Reviews reports and estimates for client specific accuracy within five business days of receipt and respond accordingly
- Monitor assigned claims for promptness and communication
- Answers questions regarding coverage and provides guidance to Independent Adjusters on claims handling
- Communication system and reporting updates to field staff and management
- Corresponds with policyholders while delivering excellent customer service
- Respond to all communications within five business days
- Train new staff on client specific reporting guidelines, claims management system and estimating platforms
- Oversees claims to completion
- Handle supplemental claims, negotiation of settlements, prepares settlement letters, denial letters, Reservation of Rights, and other letters as needed
- Draft reports and prepare requests for authority
- Answers and directs overflow phones calls when necessary
- Documentation of all claim activities
- Correspond with and negotiate with carriers, adjusters, insured’s, contractors, public adjusters, and attorneys
- Audit carrier claim files as to the quality of adjuster claims handling
- Examine and interpret insureds’ policies, forms in force, and other records
- Use varying methods of investigation, including taking recorded statements, consulting with police, inspecting property damage, and reviewing documents
- Estimate cost of repair, replacement, or compensation.
- Conducted thorough investigations of complex claims, resulting in accurate assessments and expedited resolutions.
- Managed high-value claims, ensuring accurate documentation and appropriate payouts.
- Negotiated fair settlement amounts with policyholders, maintaining company profitability and client trust.
- Developed strong relationships with insurance agencies, fostering collaboration on claim management strategies.
- Coordinated with legal counsel on litigated cases to protect company interests and minimize financial exposure.
- Mentored junior adjusters to improve their skills and promote professional growth within the team.
- Maintained compliance with state regulations by staying up-to-date on industry changes and implementing necessary adjustments.
- Collaborated with other departments to improve overall claims handling processes and enhance interdepartmental communication.
Sr. Disability Claims Representative III
Sedgwick Claims Management Services
07.2017 - 10.2018
- Analyzes approves and authorized assigned claims and determines benefits due pursuant to disability plan
- Reviews and analyzes complex medical information to determine if the claimant is disable as defined by the disability plan
- Utilizes the appropriate clinical resources in case assessment (in duration guidelines, in house -clinicians)
- Communicates with the claimants’ providers to set expectations regarding return to work
- Determine benefits due, make timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI) and other disability offsets
- Coordinates clearly with claimant and client on all aspects of claim process by either phone and / or written correspondence
- Informs claimants of documentation required to process claims, required time frames, payment information and claim status either by phone, written correspondence and :or claims system
- Coordinates investigative efforts ensuring appropriateness, provides through review of contested claims
- Evaluates and arranges appropriate referral of claims to outside vendors for physician advisors’ reviews, surveillance, independent medical evaluation
- Negotiates return to work with or without job accommodations via the claimant’s physician and employer
- Recruit qualified providers through a strategic recruitment plan based on the needs of the organization
- Develop rapport with providers and maintain on-going communication throughout the recruiting process from initial contact to contract
- Negotiate fees and rates.
Senior SME Specialist
Cognizant Technology Solutions
05.2016 - 07.2017
- Audit processed State Workers Compensations, Commercial and Medicare Claims using various systems, and SharePoint, Claims X Systems
- Institutional and facility claims Investigating and coordinating resolution of Disability, short term/long term appeals and grievance cases for Medicaid, Medicare, Medicare Part C, Special Needs and Choice plan claims
- Provide clear verbal and written communication to members and providers regarding the claims
- Resolve assigned claims in a timely manner and error free
- Prepare service appeal cases summaries for Medical Director
- Prepared FSA HSA Paper and Cobra Plans
- Work processes, monitor timelines, prioritize work, and escalate issues to leadership as appropriate
- Other duties as assigned
- Process claims in Faucets/ SharePoint Systems and EPIC software for facility billing.
Lead Analyst & Contract Negotiations Specialist
PP of America
04.2014 - 05.2016
- Team Lead Position to 20 staff
- Processed high dollar medical appeals claims developed training and useful material for team assisted and hiring/firing process and reviews of the team of 15-30
- Adjusted workflow to meet department goals
- Was in control of staff PTO and days off schedule
- Did peer disciplinary actions and implemented training and counseling to peers prior to all ups
- Conduct in-depth research for clients with complex billing inquiries and develop customized plans to clients’ needs and liaison needs
- Ensure all accounts are in compliance with HIPPA laws and federal & state regulations
- Monitored staff calls for compliance and regulatory issues
- Consistently proven to recover over 85% of revenue assigned per insurance carrier
- Coordinate with management in handling the write-off and adjustment process for accounts
- Conduct all aspects of contract negotiations with carriers, ensuring the inclusion of reimbursement fees that maximize revenue & retain customers per regulation guidelines
- Analyze accounts to identify short pays and re-bills to ensure full payment is received
- Reviewed claims for proper payment from various Payers on commercial, Managed Care and Out of Network and In Network Payers.
Team Leader and Trainer
Hyperion Solutions
03.2010 - 04.2014
- Team leads of 15-30 created daily and weekly reports to see team daily goals were met
- Processed audits on Workers Compensation, short term and long-term disability claims
- Prepared staff HSA, HSA accounts
- Held department training and education for groups and individuals for improvement toward team goals
- Monitored staff for production, tardiness, PTO hours and other benefits
- Conducted interviews, termination process, employee reviews within 90 days, and yearly reviews for salary increases
- Placed employee on workflow chart to obtain goals
- Continually monitored contracts and billing to determine required payment dates, coordinated with account managers to resolve all collection issues & establish settlements, and handled contract negotiations
- Obtained treatment authorizations, verified eligibility, benefits, & coverage of patients, identified short-pays and re-bills to ensure full payment received
- Expertly handled a high call volume environment, directly and continually communicated with patients in regard to reconciliations and collections on their accounts
- Processed corrected claims promptly, avoiding timely filing denials
- Followed PCA, federal, and state rules & regulations in addition to HIPPA guidelines
- Reviewed commercial contracts for third party claims ranging from 70% to 95% of payment
- Ran daily/weekly/monthly reports for team members and making collection recommendations
- Decreased aging by 3% working directly with slow-paying Fortune 500 companies
- Filed ADP payroll reports and submitted employee time sheets
- Reached settlements with insurance carriers and filed appeals as needed and all facility claims were billed
- Established contracts with in and out of network providers.
Facility Coordinator
Care Health Service Inc
03.2004 - 03.2010
- Monitored unpaid claims, handled credentialing, initiated tracers, and obtained insurance verifications, authorizations, appeals, and secondary insurances
- Maintained accurate customer account information, investigated & resolved declined payments, and performed credit checks
- Managed care contract for TPA and out of network carriers
- Championed the implementation of coding reviews - which successfully detected programming errors early in the development process of new company software and accelerated its market launch by 15%
- Integral part of a team that introduced a new, reproducible software development methodology that directly contributed to higher-quality product releases and a 27% reduction in errors
- Conducts investigation, assigning fieldwork as necessary and appropriate, in accordance with company standards
- Determines liability
- Develops and manages collaborative relationships with physicians, clinicians, and office managers
- Build and sustain those relationships with key referral sources by making regular and consistent office visits
- Understanding the challenges and the needs of the practices and the patients they care for
- Identifying and analyzing those physician practices and opportunities to strengthen relationships
- Mediates with outside Physicians and Medical Practices to resolve conflicts and achieve consensus
- Service Line Recovery
- Providing training to practice staff as needed including training for patient referrals, physician portal, etc
- Maintain knowledge and understanding of organizational referral process(s) (to include both online and offline processes – phone, fax, web, etc.) Territory planning- the ability to work through physicians in a defined geographic area by specialty, previous referral activity (current referrers, vs
- Potential referrers, vs
- Lost/previous referrers and first-time referrers)
- Submit updates to Physician Relations on number of visits made, key issues, concerns, and opportunities
- Update physician tracking database to reflect physician outreach activities (Salesforce)
- Skillfully handled contract negotiations to include fair and reasonable terms that lead to maximizing profitability while retaining customers.
Education
Walden University
Skills
- Quantitative Research
- Statistical modeling
- Business intelligence tools
- SQL knowledge
- Big Data Analytics
- Predictive Analytics
- Data Analysis
- Performance Optimization
Certification
Florida Adjuster All Lines, 07/01/2008
References
Available upon Request
Timeline
Senior Lead Analyst
DOL Doctors Of Tampa Bay
01.2022 - Current
Senior Adjuster - Remote
Conduent
10.2018 - 01.2022
Sr. Disability Claims Representative III
Sedgwick Claims Management Services
07.2017 - 10.2018
Senior SME Specialist
Cognizant Technology Solutions
05.2016 - 07.2017
Lead Analyst & Contract Negotiations Specialist
PP of America
04.2014 - 05.2016
Team Leader and Trainer
Hyperion Solutions
03.2010 - 04.2014
Facility Coordinator
Care Health Service Inc
03.2004 - 03.2010
Walden University
Florida Adjuster All Lines, 07/01/2008
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