Pascale Fortune

Prepares and presents Zelis’ response packages to cases submitted for arbitrations at both the state and federal level under the NSA.

Provide input and guidance on the selection process for certified arbitration entities under the NSA.

Create a scalable IDR defense package through improved automation in the creation and compilation of the necessary data elements.

Responds to Notice of offer requests using proprietary programs to calculate an offer.

Drafts briefs to provide analysis dispute along with objections to support client positions in arbitration packages pursuant to federal regulations.

Ensures Claims Settlement processes deliver required information for arbitration reviews and position Zelis for optimal success.

Document stages of IDR process and outcomes within internal database and maintain an accurate record.

Communicate with IDRE’s, Clients and Providers as needed to request or provide additional information.

Provide monthly performance reporting to departmental leadership.

Maintain department productivity and quality standards.

Confirm that all documentation adheres to Zelis standards regarding privacy, compliance, legal aspects, and HIPAA standards.

Ensures all cases remain compliant with required timelines for responses and required Zelis input.

Thoroughly investigate claims by timely contacting injured workers, medical professionals, and employer representatives/witnesses and documenting investigation efforts and findings.

Determine if claims are valid under worker's compensation statutes.

Communicate with medical providers to develop and authorize treatment plans.

Review and analyze medical bills to see if they are aligned with workplace injury.

Ensure medical bill payments are remitted on a timely basis in accordance with applicable fee schedules and statutes.

Calculate and apply appropriate reserve adequacy throughout life of the claim.

Prepare required state filings within applicable time limits.

Oversee and work with legal counsel to provide information and strategic direction for litigation and/or settlement negotiations.

Ability to maintain on-going education credits in multiple states.

Assisted customers in average daily by answering questions and responding to
inquiries via telephone and electronically. Also resolved all customer complaints in a
professional manner while prioritizing customer satisfaction.

Managed and posted billing patient account payments; which included hospital and professional fees.

Reviewed delinquent accounts and assisted patients in payment collections through
offering payment plans and settlements. Contacted internal collection agencies to update patients who have settled their accounts.

Verified insurance eligibility and answered benefit questions in relation to co-pays,
deductibles, and out of pocket maximum.

Calculated figures and provided cost estimates based on insurance plan benefits and fees schedules.

Cooperated with Medicare, Medicaid, Social Security, and employer group insurance providers to
resolve eligibility and billing issues.

Contacted medical and ambulance providers on patient's behalf to resolve and avoid balance billing errors.

Verified accuracy of Explanation of Benefits and advised insurance companies to revise any errors.

Obtained information from insurance carriers and patients when services billed are denied for reasons such as incorrect insurance information, demographic information and/or authorization.

Responsible for analyzing claims, following up with insurance carriers on unpaid or rejected claims, and filing secondary claims as needed.

Researched and resolved all zero payment explanations or benefits to providers and advised all options to obtain claims payments; initiated adjustments as necessary. Explained in detail denial codes in relation to CPT, HCPCS, Revenue, Procedure, ICD9/10.

Utilized as a liaison between my manager and my team, mentoring and shadowing new hires and answering any questions they may have after training.

Coordinated monthly team meetings and special events for 20-25 employees and became an active part in team's event committee including rewarding team members for years of service to Kaiser Permanente to help build morale.

Managed inbound and outbound customer calls effectively and efficiently in a
complex, fast paced and challenging call center environment.

Provided sales consultations on the functional and stylistic benefits of each custom
product.

Used a consultative sales approach to understand and meet customer needs.

Tailored sales approaches and techniques to specific client needs to increase
marketing effectiveness.

Developed strong rapport with customers and created a positive impression of the
business.

Built customer loyalty and retention by delivering excellent shopping experiences.

Identified prospects' needs and developed appropriate responses along with
information on fitting products and services.

Effectively managed a high-volume of inbound and outbound customer calls.

Tracked the progress of all outstanding auto insurance claims.

Collected, analyzed and validated all claim processing data efficiently.

Answered questions posed by insured and attorneys.

Investigated claims involving potential and suspected fraudulent activities.

Researched and reviewed information to determine validity of insurance claims and
contacted companies and customers about decisions.

Contributed ideas and offered constructive feedback at daily debrief and monthly
training meetings.

Processed 20-25 claims daily.

Collaborated with field support team, quality control, file review, team lead and
adjusters to deliver support specific to claim assignment

Accessed credit report to evaluate customer credit worthiness and assisted with opening new accounts for credit, personal loan and mortgage lending.

Assessed customer financial situations to develop strategic financial planning solutions.

Met with multiple prospects daily resulting in a high customer retention rate.

Generated reports detailing various metrics and account information.

Performed administrative tasks such as daily, monthly, and end of day revenue
reports.

Actively and continuously contacted new and existing customers per monthly basis to discuss new products and services.

Assisted management with the finalization of the annual expense budget.

Processed payments and applied to customer balances.

Built customer relationships by acting as the liaison between the bank teller and sales
teams.

Worked closely with team members to deliver project requirements, develop solutions and meet deadlines.

Coordinated daily cash reconciliation in high-volume location

Accessed computerized financial information to answer questions related to specific accounts.

Reconciled cash drawer and resolved discrepancies.

Counted and packaged currency and coins and turned in excess cash to maintain drawer security.

Sold and cross-sold bank products to new and existing customers.

Built and strengthened customer relationships by leveraging excellent communication skills.

Maintained friendly and professional customer interactions.

Processed exchange and foreign currency, cashier's checks, traveler's checks, and money orders.

Assisted customers with money vault allowing privacy and utilizing discretion.