Ronkesha Carter

Supports comprehensive coordination of medical services including intake, screening to Medical Services Programs.

Promotes/supports quality effectiveness of Healthcare Services.

Performs intake of calls from members or providers regarding services via telephone, fax, EDI.

Utilizes MedCompass/ATV and other systems to build, research and enter member information.

Screens requests for appropriate referral to medical services staff.

Approve services that do not require a medical review in accordance with the benefit plan.

Performs non-medical research including eligibility verification, COB, and benefits verification.

Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.

Promotes communication, both internally and externally to enhance effectiveness of medical management services

Protects the confidentiality of member information and adheres to company policies regarding confidentiality

Communicate with Case Managers, when processing transactions for members active in this Program

Supports the administration of the pre-certification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.

Handle escalated claims files that have complex contents or additional living expense damages.

Conduct a thorough coverage investigation of the loss and ensure the policy was applied correctly

Use advanced video technology to collaborate with onsite vendors to identify damages and write a contents damage estimate from a virtual setting

Communicate empathetically with customers and help them through their claim process in a fast, fair and easy manner

Negotiate claim settlements with customers in accordance with business unit standard methodologies

Coordinate with structure adjuster’s to ensure holistic handling of the claim file

Use data and analytics to tell a story and influence decision making

Maintains positive customer relationships by exhibiting a courteous and professional demeanor in all communication with customers, dealers and agents, as well as internal employees.

Accurately documents information in timely and efficient manner per departmental procedures

Determines properly adjudicate claims.

Documents the claim file with notes, evaluations, and decision elements

Completes other tasks as directed by management

Contacts customers, agreement holders, others to secure necessary documentation and information as needed and directed. Confirms facts and determine additional needed follow-up

Continuing communication with assigned TPA or strategic partner on claim issues

Monthly report reconciliation with assigned TPA or strategic partner

Provides assistance with addressing incoming calls and customers.

Collect and analyze relevant information to determine claim validity, coverage and liability.

Investigate and evaluate claims by conducting interviews, reviewing documentation, and gathering evidence.

Document interactions, conversations and activities related to claims in a clear and concise manner using company systems and tools.

In a team environment, manage a high volume of incoming telephone calls from policyholders, agents and other parties involved in the claims process.

Provide outstanding customer service by actively listening to policyholder concerns, empathizing with their situation, and demonstrating a commitment to resolve the claim.

Maintains file information to ensure accurate record of claims; continually reviews and monitors progress and expense of claims in pending

Settles and authorizes payment with claimants.

Identify and escalate files with more significant indemnity exposure or attorney representation to supervisor for review.