General Studies

I guided the member through their member plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines. Created an emotional connection with our members by understanding and engaging the member to the fullest. Answered questions and resolved issues based on phone calls/letters from members, providers, and plan to champion for our members' best health. Provided the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc. Explained the member's rights and responsibilities in accordance with contract. Processes claim referrals, new claim hand offs, complaints (member/provider), grievance and appeals (member/provider) via target system. Educated providers on our self-service options. Assisted in compiling claim data for customer audits. Determined applicable coverage provisions and verified the members plan eligibility relating to incoming correspondence and internal referrals.

Handle insurance claims as a third-party adjuster. Filed claims by policyholders in a highly secure call center environment. Planned and schedule work needed to process and investigate claims. Reviewed claims to ensure adherence with company practices and procedures. Reported over payments, underpayments and other irregularities. Evaluated and investigated policy coverage's, liability and damages in a timely manner following a set of general claim and statutory guidelines. Analyze information gathered by investigation and report findings and recommendations. Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed

I investigated, evaluated, negotiated, and concluded claims including verification of coverage, legal liability and extent of damage to property, which required contact by telephone and correspondence. I also examined claims submitted by insureds and/or third parties, or such claims assigned from other claim units, for additional or specialized investigation as necessary for claim resolution. I assigned claims and tasks, including claims which may involve large loss, multiple contacts, complex coverage issues and multiple site inspections. I prepared, and/or reviewed property estimates, and contents estimates in loss settlements. I assisted agents in the resolution of claims.

Serving as Dispatch Supervisor for the largest carpet cleaning company in the United States. As Dispatch Supervisor, I was regularly responsible not only for Columbus but also Dayton and Cincinnati. The position included but was not limited to routing of all trucks, customer service, supervision, scheduling, tracking of hours, troubleshooting, training and tracking of the day ‘s goals. Dispatching of fleet and controlling the days movement.