KIMBERLY SIMS
Newnan
Summary
I am a dedicated professional with years of medical experience which includes but is not limited to doctor’s assistant, operation room preparation, eligibility determination, appointment scheduling, inpatient and outpatient support, medical terminology, anatomy & physiology, pathology, Medicaid Training, Social Security Disability Training, Patient Advocate Lead, Regional Supervisor, Case Management. I have excellent organizational Skills, time management, Customer Service, Escalated Customer Calls and am an initiative-taking employee. I challenge myself to deliver high quality results with an eagerness to learn and improve. Strong Collaborator, Team Builder, Encourages Staff “As A Team We all can be Successful.”
Overview
11
11
years of professional experience
Work History
Sr. LTD Claims Manager
Lincoln Financial Group
03.2022 - 01.2025
- Manage LTD, STD, STAT claims, Worker Comps, MVA
- Manage 150-180 LTD claims
- Completed initial interview
- Document claims
- Knowledge of Understanding the disability claim management concepts
- Review medical records to make disability determination
- Review LTD Policy and Customer Profile
- Understanding ERISA process in making determination timely
- Conduct Pre-ex investigation
- Conduct and review Pharmacy report
- Conduct and review EOI
- Review and convert escalation claim from STD to LTD within 3 days of receiving claims
- Review claims for ongoing management
- Make determination to refer claims to Any Occupation or Permanent Disability Unit
- Notice & Proof pending LTD claims (21days, 45days new claim) (30days, 45days, 75days, ongoing claims)
- Request medical records to make determination
- Present claims to in Clinical consult to assist with making determinations
- Refer claims to payment services upon approval
- Answer high volume calls
- Assist with Payment Services (initial payment, Advance pay and close, SSDI Offsets, Approve and Close, FICA taxes withholdings, Federal income taxes)
- Completed training in California State Disability Insurance (SDI), California Voluntary Disability Insurance (VDI), California Paid Family Leave (CPFL)
- Communication emails with Employer’s for EDOC (Effective date of coverage) RTW returned to work dates), LDW (Last day work), Premium deduction
- Send Notice & Proof letter and Notice & Proof Subsequent letter
- Send Denial, Approval, change of definition, withdrawal, ROR (Reservation of Right), Closure, Suspension of Benefits, ERISA Extension letters and explanations to claimants
- Request Occupational Analysis and Vocational Services Transferable
- Assist with conducting morning huddles
- Assist with other Disability Case Managers Desk Coverage
- Completed Monthly Focus List
Case Manager
Rose International Inc/Untied Health Group
11.2021 - 03.2022
- Complete monthly telephone contacts (using a template and criteria)
- Assist the assigned case manager with contacts to various medical offices to obtain 3008, LTC Renewal forms
- Assist the plan to complete wellness calls to members as needed
- Assist the Region's manager with special projects as needed to maintain compliance with contractual requirements
- Complete Monthly contact with MD office for all clients follow up based on United Healthcare and SS Disability criteria
Regional Supervisor- Eligibility & Enrollment Services
Conifer Healthcare/ WellStar
07.2016 - 11.2021
- Company Overview: Atlanta Georgia
- Supervisor 14 Employees/ 4 local Hospital within Georgia
- Assisted staff in resolving issues with account, DFCS, Social Security Disability Cases
- Assist Staff meeting monthly Goal POE
- Provided Unit inventory to assigned facilities twice a month
- Completed Spot Audits for all staff monthly
- Completed weekly reports per Revenue Cycle
- Assist working accounts for resolution of Inventory/ set up email logs for local DFCS; inquiries/ case status
- Preparing for next Iron Mountain Clean Up/Pick Up
- Attended Daily Huddle, Medical Review periodically throughout the month/Complex Case meeting, Hospital CFO’s periodically throughout the month
- Continued Training for all staff/Accounts and Desk Review/ Next Step Resolution
- Reviewed Facility Dashboard Reports
- Completed all tasks requested by Manager, Director, Senior Director, Vice President
- Travel through 7 Facility when help needed (Georgia, North Carolina, Alabama)
- Complete and Submit Expense Report
- Send Monthly Physician POE Report to local MD office
- Knowledge Of Medicaid Programs
- Knowledge of Financial Assist Program
- Knowledge of Social Security Disability Program
- Conduct Interviews for New Hire
- Power point for Medicaid Process/ Spot Audit Process
- Assist Creating New Hire Manuals
- Attend Regional Team Meeting
- Preform Performance Action Play / One on One
- Approves time in Kronos
- Approve employees’ vacation
- Provide daily workflow for Lead/assistant
- Create and update seven different Hospital Protocols
- Review patient’s medical records to make determination
- Atlanta Georgia
DME Qualifier- Healthy at Home Medical Equipment
Carolinas Healthcare System
06.2014 - 07.2016
- Company Overview: Charlotte, NC
- Qualify patients for O2, Bent Metal, and other home equipment
- Verifies all patient insurance and physician information
- Research patients’ chart and medical doctors’ notes
- Creates sales orders for new equipment
- Dispatch orders for delivery techs to deliver
- Acts and communicates in a professional manner, appropriate for the healthcare setting
- Proficient with Medicare, Medicaid, and Commercial insurance qualifications
- Provides the correct ICD-9 –ICD .10codes
- Call patients to ensure their direct contact information and address
- Provides quality control to ensure proper billing
- Uploading information from the patient’s chart to create an order
- Work with Account Executive’s and Transition Liaison
- Charlotte, NC
Education
Associate degree - Computer Business
Central Piedmont Community College
Charlotte, NC01.1992
Skills
- Epic
- Windows
- Excel
- Outlook
- Centricity IDX
- Star
- PeopleSoft
- Cerner
- ICD-9
- ICD-10
- Bright tree
- CPR ProVation
- Allscripts
- Passport
- ACE
- PBAR
- Gammis
- VI Web
- Accurint/Fast Data System
- RAMP
- PowerPoint Showcase
- Micro Soft Word
- Microsoft Office
- EPIC Super User
- SharePoint
- Skype for Business
- Webex
- Kronos
- System One
- One note
- Clinical Referral
- Microsoft Edge
- Google Chrome
Timeline
Sr. LTD Claims Manager
Lincoln Financial Group
03.2022 - 01.2025
Case Manager
Rose International Inc/Untied Health Group
11.2021 - 03.2022
Regional Supervisor- Eligibility & Enrollment Services
Conifer Healthcare/ WellStar
07.2016 - 11.2021
DME Qualifier- Healthy at Home Medical Equipment
Carolinas Healthcare System
06.2014 - 07.2016
Associate degree - Computer Business
Central Piedmont Community College
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