Rashonda Gainer

• Reviewed medical records and documents to determine coverage eligibility of claims for insurance benefits
• Performed data entry into the computer system to record information regarding claim status
• Investigated discrepancies in claims and resolved issues with customers via telephone or written correspondence
• Provided guidance to other staff members regarding claim processing rules and regulations
• Collaborated with internal departments such as Underwriting, Provider Relations, Medical Management, Quality Assurance, as needed
• Maintained up-to-date knowledge about changes in healthcare reform legislation affecting provider reimbursements
• Paid and processed claims within designated authority level
• Double-checked and reviewed documentation for denied and accepted insurance claims
• Provided guidance, assistance and training to new staff on the proper procedures for handling customer inquiries and complaints
• Motivated team members to maintain targeted turnaround time to obtain processing goals
• Evaluated and managed long-term disability claims, conducting investigations and coordinating with healthcare providers to ensure accurate assessments.
• Communicated with claimants and stakeholders to provide updates, resolve issues, and ensure compliance with policies and regulations.
• Monitored ongoing claims for changes in medical or employment status, preparing detailed reports to support benefit decisions.

• Manage Long Term and Short Term Disability and leaves that are concurrent with

Long Term and Short Term Disability and Workers' Compensation.

• Independently investigate, evaluate and adjudicate claims of high

degree of complexity.

• Assist in claim auditing and claim denial review.

• Collaborates with team members and management in identify and

implementing improvement opportunities.

• Participate in finalist presentations and on-going client meetings.

• Fully investigates all relevant issues, providers, payment or denials,

promptly and in full compliance with departmental procedures and

unfair claims practice and regulations.

• Constant communication with Human Resource to provide updates

on claims status.

• Process Payroll and run payroll reports to assure Claimants are paid

timely.

• Maintain a high level of confidentiality and abide by HIPPA rules

and regulations.

• Regularly communicates and interacts with treating providers

and/specialists to obtain appropriate medical information needed to

complete initial LTD/STD/FMLA/LOA approvals or continued

recertification of benefits.

• Reviews and provides specific information to questions/concerns

from internal/external stakeholders (e. g. internal partners,

policyholders, brokers, etc.) by applying core knowledge obtained for

the role.

• Assist in denial appeals and second chance reviews.

• Manage Long Term and Short Term Disability and leaves that are concurrent with Short Term Disability and Workers' Compensation
• Independently investigate, evaluate and adjudicate claims of high degree of complexity
• Assist in claim auditing and claim denial review
• Collaborates with team members and management in identify and implementing improvement opportunities
• Participate in finalist presentations and on-going client meetings
• Fully investigates all relevant issues, providers, payment or denials, promptly and in full compliance with departmental procedures and unfair claims practice and regulations
• Constant communication with Human Resource to provide updates on claims status
• Process Payroll and run payroll reports to assure Claimants are paid timely
• Maintain a high level of confidentiality and abide by HIPPA rules and regulations
• Regularly communicates and interacts with treating providers and/specialists to obtain appropriate medical information needed to complete initial LTD/STD/FMLA/LOA approvals or continued recertification of benefits
• Reviews and provides specific information to questions/concerns from internal/external stakeholders
• Internal partners, policyholders, brokers, etc.) by applying core knowledge obtained for the role
• Assist in denial appeals and second chance reviews

• Process assigned claims for payment or denial in accordance with established procedures and guidelines, in a timely manner and meeting departmental quality/production standards
• Reviews and provides specific information to questions/concerns from internal/external stakeholders
• Internal partners, policyholders, brokers, etc.) by applying core knowledge obtained for the role
• Reviews submitted claim information for payment
• Ensures the accuracy and completeness of submitted claims
• Must be able to meet predetermined productivity and quality standards
• Applies core knowledge obtained for the role to effectively communicates verbally and in written form with internal/external stakeholders to obtain needed information while maintaining a professional demeanor in all interactions

• Provide timely and effective claim service; handle non-contestable claims
• Conduct technical investigation of complex contestable claims, accidental and disability claims
• Handle administration of STD and FMLA/LOA disability claims arising under disability insurance or leave of absence policies
• Educate employees to set appropriate expectations both verbally and in writing
• Regularly communicates and interacts with servicing providers and/specialists to obtain appropriate medical information needed to complete initial STD/FMLA/LOA approvals or continued recertification of benefits
• Documents claim decisions/actions and enter data into appropriate claim processing systems
• Inbound Calls to increase customer satisfaction Assist with Training and coaching of new hires