Sandra McGowan
New Orleans,LA
Summary
Well-qualified Training Specialist adept at planning and implementing onsite and remote training programs. Authoritative and clear communicator with enthusiastic style and insightful approach. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
15
15
years of professional experience
Work History
Claims Trainer
Pan-American Life Insurance Group
01.2016 - 08.2023
- Upgraded to cloud systems and conducted UAT, in partnership with business, to ensure all modules behaved as expected and data was being accurately migrated.
- Trained all users on all modules to ensure efficient module utilization.
- Advised Senior Management of strategic training plans to enhance technical and leadership skills.
- Conducted one-on-one sessions with managers and stakeholders for leadership effectiveness coaching.
- Performed training knowledge transfer sessions to SME's enabling them to guide and coach staff.
- Developed and revised training curriculum, manuals, job aids, and coursework based on changes in the insurance industry.
Claims Quality Auditor
Pan American Life Insurance
06.2008 - 12.2015
- Reviewed critical errors from EDI submissions and analyzed claims for data corrections
- Maintained knowledge on policies and procedures of claims processing on a daily and consistent basis
- Analyzed complex coverage issues, adjudicated claims according to Centers for Medicare & Medicaid Services, Investigation for claims settlement, strategized appropriate action for claim and diary files
- Review and interpret employer plans of health coverage and excess insurance policy to individual claims
- Audit submitted claim documents for sufficient data, verify that benefits were paid correctly and in accordance with appropriate plans and policies, and determine liability
- Communicates in writing and verbally with TPA/client as needed to resolve claim processing issues
- Set claims reserves and adjusts as needed
- Keep all reserves current
- Authorize checks for amount of liability and communicate to TPA/client reasons for any amounts not covered by excess policy
- Refer large dollar claims and trigger diagnosis to preliminary claims and case management departments.
Education
Bachelor of Science - Computer Information Systems Technology
Southern University At New Orleans
New Orleans, LASkills
- Skills & Abilities
- Successful Qualifications in Life, Health, Accident, P&C Products, Appeals & Grievance Management, Epic, Electronic Billing and Coding systems ICD-10, CPT, HCPCS coding guidelines, strong leadership, mentoring and professional development Repricing methodologies(Medicare, DRG, RBRVS), PPO Contracting and Credentialing, Benefits Management & Administration, HMO reinsurance, Risk and Feasibility Assessment, Strategic and Operations Planning, Corporate Claims, General Liability, Workers Compensation/Occupation Accident, Disability Income, FMLI Absence Leave, Training & Development, Program Management and Development, Global and Regulatory Compliance, Stop Loss Claims Program, Risk Management, TPA Oversight and Audit, Subrogation Management, Project & Change Management, PIVOT Tables, PIVOT Reporting, VLOOKUP
- Advanced in Microsoft Office Suite, Learning Management and HRIS, HTML, AS400 platform, Payer Software,Windows Operating Systems, Data Mining & Queries, Salesforce, Workday
Timeline
Claims Trainer
Pan-American Life Insurance Group
01.2016 - 08.2023
Claims Quality Auditor
Pan American Life Insurance
06.2008 - 12.2015
Bachelor of Science - Computer Information Systems Technology
Southern University At New Orleans
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