Quantesia McClain
York
Summary
Developed expertise in overseeing complex claims processes and implementing regulatory compliance in fast-paced environment. Transitioning to new field with focus on utilizing transferable skills in data analysis and effective communication. Dedicated to contributing to organizational success through efficient problem-solving and strategic thinking.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Long term disability claims manager
New York Life
05.2023 - Current
- Proactively manage your block of medical claims by regularly talking with and knowing your customers, their level of functioning, and having a command of case facts for each claim in your block
- Find customer eligibility by reviewing contractual language and medical documentation, interpret information and make decisions based on facts presented
- Ask focused questions of internal resources (nurse, behavioral, doctor, vocational) and external resources (customer, employer, treating provider) in order to question discrepancies, close gaps and clarify inconsistencies
- Provides timely, balanced and accurate claims reviews, documentation and recommended decisions in a time sensitive and fast-paced environment and in accordance with state and department of insurance regulations while independently managing an assigned caseload of moderately complex claims which consists of pending, ongoing/active and appeal reviews
- Clarifies and reconciles inconsistencies when gathering information during claim evaluations and collaborates with Fraud Waste and Abuse resources as needed and proficiently calculates monthly benefits due after elimination period, to include COLA, Social Security Offsets, and Rehab Return to Work benefits, and other non-routine payments
- Compiles file documentation and correspondence requiring extensive policy and factual detail
- Analyzes information to determine if additional information is needed to make a reasonable and logical claims determination based off the information available and collaborates effectively with both external and internal resources, such as physicians, attorneys, clinical and vocational consultants, as needed, to gather data such as medical/occupational information in order to ensure reasonable, thorough decision
- Interacts and communicates effectively with claimants, customers, health care providers, attorneys, brokers, and family members during claim evaluations while addressing and resolving escalated customer complaints in a timely and thorough manner
- Identifies and refers appropriate matters to our appeals, complaint or litigation support areas
- Find customer eligibility by reviewing contractual language and medical documentation, interpret information and make decisions based on facts presented
Long term disability claim manager
Wells Fargo
05.2013 - 09.2022
- Conducted thorough investigations of medical claims, reviewed policy documents, and determined claim eligibility and coverage
- Find customer eligibility by reviewing contractual language and medical documentation, interpret information and make decisions based on facts presented
- Analyzed and evaluated claims to ensure compliance with company policies and procedures, as well as state and federal regulations
- Negotiated with claimants, attorneys, and other stakeholders to reach fair and equitable settlements
- Maintained accurate and detailed records of claims activity and communicated updates to all relevant parties
Family medical leave Claim Specialist
Citi
06.2004 - 05.2013
- Reviewing and conducting analysis of claims to ensure regulatory requirements are appropriately applied
- Processing professional, outpatient facility, and inpatient facility claims for Medicare, Medicaid, and marketplace plans
- Documented all claim activity in accordance with company Clearly documents claims research results and root cause of processing errors
- Recommends remediation plan and assists with monitoring of claims reprocessing
- Responsible for ensuring the claims research is completed accurately by the established timelines
- Assisted in the development of new claims procedures and policies to improve efficiency and accuracy
Education
Bachelor of Science - Business Administration
York Technical College
Rock Hill, SC12.2024
Nurse Care Certificate - undefined
York Technical College
Rock Hill, SC05.2022
High School - undefined
York Comprehensive High School
York, SC06.2004
Skills
- Claims processing and management
- Decision Quality
- Action Oriented
- Claims investigation and analysis
- Negotiation and settlement
- Policy interpretation and compliance
- Claims software and systems
- Communicate Effectively
- Detail-oriented and organized
- Ability to work under pressure and meet tight deadlines
Summary
- 10+ years of experience in the insurance industry, with a focus on claims processing and management.
- Proficient in disability claims processing software and systems, including medical claims, Excel, State leave laws, worker's compensation, ERISA, Social Security Claims Analysis, Ventiv Claims, MediClaims, Series3000, Smart Data Solutions, Euclid, Cloud Claims, MedEvolve BriteCore, Guidewire ClaimsCenter, Applied Epic, Pega Claims Management, LexisNexis Carrier Discovery and A1 Tracker.
- Skilled in reviewing and analyzing complex claims, negotiating settlements, and making accurate claim decisions.
- Proven ability to manage multiple priorities and meet tight deadlines in a fast-paced environment.
- Strong communication skills with the ability to effectively interact with internal and external stakeholders.
Certification
- CPR/AED Certification
- Basic Life Support Certification (BLS)
- Certified Nursing Assistant (CNA)
Timeline
Long term disability claims manager
New York Life
05.2023 - Current
Long term disability claim manager
Wells Fargo
05.2013 - 09.2022
Family medical leave Claim Specialist
Citi
06.2004 - 05.2013
Nurse Care Certificate - undefined
York Technical College
High School - undefined
York Comprehensive High School
Bachelor of Science - Business Administration
York Technical College