Erica N. Lamb
Chicago,IL
Summary
Experienced with employee benefits management, including plan design and compliance. Utilize strong communication and analytical skills to improve benefits processes and employee understanding. Knowledge of regulatory requirements and best practices ensuring effective benefits administration.
Overview
21
21
years of professional experience
Work History
Benefit Specialist
Dearborn Group
Lombard, IL
09.2023 - Current
- Interpret and verify employer-sponsored benefits based on Summary Plan Descriptions (SPDs) to ensure accurate eligibility and coverage details for disability claims.
- Review, analyze, and input benefit information into the Disability Claims System (DCS), ensuring all data is properly coded to support timely and accurate claims processing.
- Collaborate with internal departments, including claims examiners and underwriters, to clarify plan provisions and resolve discrepancies that may impact claim outcomes.
- Maintain compliance with company policies and regulatory standards while managing sensitive claimant information.
- Assist in streamlining procedures and identifying improvements to enhance the accuracy and efficiency of benefit setup and claims administration.
Disability Claims Manager
Jacobson Group (Insurance Staffers, Inc)
Chicago, IL
07.2021 - 12.2022
- Adjudicated disability claims.
- Reviewed medical information to determine appropriate extension of approvals based on the Medical Disability Guidelines.
- Generated structured correspondence regarding the denials of claim for various denial reasons.
- Management & adjudication throughout the life-cycle of the claim.
- Documents processed and reviewed for accuracy.
- Review policies to provide all applicable benefits for each claim.
Direct to Consumer Loan Processor
Caliber Home Loans
Coppell, TX
10.2020 - 07.2021
- Review loan files for completeness and accuracy in a timely manner to ensure the loan can be processed, closed and funded prior to the rate lock expiration date.
- Document processing and review.
- Obtain data from various agencies and departments to fulfill FHA/VA streamline and full-document loan requirements.
- Maintain timely communication with Borrowers and internal clients on the progression of the loan.
- Utilize various systems or services to obtain credit reports, Undisclosed Debt Monitoring (UDM), Fraud Manager reports.
- Generate the initial closing disclosures for review and balance with the title company prior to re-submission to Underwriting.
- Gather requested documentation needed for the subordination of liens.
- Schedule closing date and properly review the final closing disclosure, rate/term, payments and subsequent dates with the Borrower prior to the closing day.
Claims Adjuster
Combined Insurance – Chubb Company
Chicago, IL
11.2018 - 10.2020
- Adjudicated insurance claims for various coverages under Accident, Critical Illness, Disability and Sickness policies.
- Performed Contestable & Pre-existing condition investigations.
- Initiated independent medical evaluations and vocational coordination for return to work.
- Management & adjudication throughout the life-cycle of the claim.
- Documents processed and reviewed for accuracy.
- Review policies to provide all applicable benefits for each claim.
- Perform due diligence interviews with policy holders to confirm the validity of the claim and the documents submitted to support the claim.
- Contact providers to request medical documentation to support the claims.
- Pay benefits according to policy and benefit schedule rules.
Quality Review Analyst
Aerotek Contract - Blue Cross Blue Shield HCSC
Chicago, IL
08.2018 - 11.2018
- Facilitated the final resolution of member and provider appeals.
- Facilitated access to appeal files to members or member designee under federal guidelines.
- Supported team members in appeal resolutions.
- Managed individual appeal inventory through the appropriate corresponding deadlines.
- Documents Processed and Reviewed for accuracy.
- Reviewed file history to determine the level of appeal needed for the member or provider.
- Reviewed member’s supporting medical documentation and policy information for accuracy.
- Initiated Independent Medical Evaluation (IME) referrals.
- Sent requests for the medical reviewer to address specific medical questions during the evaluation.
- Reviewed the completed IME for accuracy; resubmit for corrections if needed & document the resolution.
HEDIS Clerk II
Aerotek Contract - Blue Cross Blue Shield HCSC
Chicago, IL
01.2018 - 05.2018
- Initiated requests for medical records to complete data abstraction for the annual Healthcare Effectiveness Data Information Set (HEDIS) audit measures specific to Medicaid/Medicare in the Government Programs Division.
- Worked with Providers and their office staff to arrange the timely collection of medical records for the members identified for the HEDIS audit.
- Educated Providers on HEDIS measures, objectives, and requirements for audit compliance.
- Documents reviewed for accuracy.
- Documented and reviewed medical records to confirm the data received matches the request for the appropriate measures for data abstraction and compliance.
Care Senior Associate, Health Services Department
Cigna HealthSpring - Managed Care Organization
Chicago, IL
01.2016 - 01.2018
- Managed day-to-day department functions and special projects pertaining to complex and behavioral health care coordination services for Medicare-Medicaid Plan (MMP) and Medicaid Integrated Care Plan (ICP) members.
- Execute concurrent projects while consistently meeting deadlines.
- Complete member specific Care Coordination assessments and outreach.
- Locate viable community and medical resources for members.
- Generate & review daily reports for member admission and discharge to hospitals, rehab, skilled nursing facilities (SNF) and long-term acute care facilities (LTAC).
- Assign field or telephonic coordinators to assess the needs of members.
- Assign and track daily workload for internal staff, telephonic and field case coordinators based on specialty and location.
- Complete authorization requests for Thresholds behavioral health admissions and service dates of treatment.
- Request clinical documentation to support the extension of authorization requests.
- Utilization review; completion of authorizations for patient health care needs based on medical necessity and review of SOAP notes.
- Educate members on case management services available.
- Provide resources and case management support.
- Train new staff.
- Update and implementing new workflows that effectively meet target goals.
- Track and monitor all case manager workload.
- Manage special projects; Health Services Department Liaison for client services administered for Be Well Partners in Health, Thresholds, and the CHS care coordination team.
- Outreach to members regarding redetermination process with Illinois Department of Healthcare Family Services (HFS) to maintain healthcare coverage.
- Assist leadership team with creating and implementing workflows for new and current projects.
- Care Coordination & Outreach to members for annual health risk assessment and evaluation for ongoing care coordination needs and assign for follow-up.
- Assist with in office documentation & preparation for Medical Data Abstraction.
- Conduct internal audits on RTCA outreach & quality reviews for compliance.
Sr. Disability Representative
Sedgwick CMS
Chicago, IL
07.2010 - 01.2016
- Analyzed, adjudicated and authorized disability management claims with complex medical documentation; determine benefits due pursuant to an employer’s disability plan/summary plan description (SPD); communicate with claimants and claimant’s providers to set expectations regarding claim process, return to work procedures and expectations.
- Subject matter expert and resource liaison for implementation of multiple client accounts.
- Process improvement regarding work utilization.
- Manage medical disability claims to ensure compliance with plan provisions, duration control, and the Official Disability Guidelines (ODG).
- Review clinical exam notes required to process the claimant’s disability claim.
- Evaluate & arrange appropriate referral of claims to outside vendors for physician advisor reviews, independent medical evaluations, surveillance, etc.
- Utilize the appropriate clinical resources in claims assessment; communicate clearly with claimant & client on all aspects of claims process.
- Medically manage claims ensuring compliance with control guidelines & plan provisions.
- Make timely claims payment/approvals & adjustments including offsets due to State Disability or Social Security Disability Insurance entitlements.
- Refer for subrogation due to litigation or liability insurance.
- Assist with implementation and modification of pending processes to maintain account/client satisfaction and retention.
- Assist with audit reviews to meet client performance guarantees.
- Managed the concurrent Family Medical Leave and Leave of Absence cases.
- Designated as the Short-Term Disability & Family Medical Leave department Subject Matter Expert (SME).
- Provide process improvement training and coaching to enhance Best Practices to meet Performance Guarantees (PG).
- Identify opportunities and develop recommendations for process improvements.
FMLA Specialist I
Sedgwick CMS
Chicago, IL
01.2010 - 01.2011
- Oversaw and managed Family Medical Leave Act (FMLA) cases to determine eligibility and entitlement; analyze medical certification; provided consultation and subject matter expertise in evaluating compliance with state and federal regulations.
- Performed special projects related to FMLA management; identified needs, developed long-range plans & initiatives for workplace and process implementation.
- Worked with managers and human resources to educate & implement job modifications/accommodations at worksite.
- Reviewed & determined approval of claimant’s request for job modifications/accommodations.
- Communicated with client and claimants regarding requests, options, & outcomes.
Customer Service Advocate
Aetna Inc. (Active Health Management)
Rolling Meadows, IL
07.2007 - 07.2010
- Enrolled members in the appropriate employer-based benefit program by answering all inquiries regarding program benefits, enrollment, and claim questions; educated and provided resources that helped members make wise decisions concerning their health care coverage.
- Verified member eligibility for Informed Care Management (ICM) Services in accordance with HIPAA.
- Tracked members contacts/events following progressive & non progressive engagements; initialized cases for Disease Management.
- Efficiently navigated multiple systems while resolving complex issues.
Family Medical Leave Act (FMLA) Coordinator
Aetna Disability & Absence Management (Formerly Broadspire)
Plantation, FL
07.2006 - 07.2007
- Received and reviewed FMLA cases using the Department of Labor federal and state legislation/regulations; Designated as the subject matter expert to provide specialized consultation and facilitate department training for new hires.
- Worked with supervising managers and HR to educate & implement job modifications/accommodations.
- Communicated with claimant regarding requests, options & outcomes.
- Determined eligibility of FMLA and State Leave, case management, initiated correspondence, claim adjudication.
- Conducted internal audits including off-shore TPA vendors; evaluated compliance with quality standards, & accuracy.
Administrative Support
Aetna Disability & Absence Management (Formerly Broadspire)
Plantation, FL
07.2004 - 07.2006
- Implemented and managed processes to meet productivity and quality standards/deadlines for the administrative unit; IVR transcription, managed implementation of electronic filing system.
- Resolved inquiries, maintained files/records, scheduled meetings, completed special projects as assigned.
- Facilitated system training; scanned & indexed images; ordered supplies & equipment.
- Conducted reviews/audits of off-shore processes for compliance.
- Tested system enhancements for department usage.
Education
Bachelor of Arts - Human Resource Management
University of Phoenix
Chicago, IL 05.2001 -
Associate of Arts - Graphic Design/Multimedia
Westwood College
Calumet City, IL 05.2001 -
Skills
Claims & Benefits Administration:
Disability Claims Management (STD, LTD, FMLA, LOA)
Claims Adjudication & Processing
Medical Records Review & Analysis (HEDIS, Medical Data Abstraction)
Official Disability Guidelines (ODG) Expertise
HIPAA, ERISA Compliance
Complex Care Coordination
Benefit Verification & Interpretation (SPDs)
Utilization Review
Independent Medical Evaluation (IME) Referral Management (Dane Street, MES)
Medicaid/Medicare Plan Administration (MMP, ICP, MMAI)
Managed Care Organizations (MCO) experience
Administration of Health Risk Assessments
Wage/Salary/Benefit Administration
Labor Law Regulations (DOL), Equal Employment Opportunity Regulation (EEOC)
Loan Processing:
Home Loan Mortgage Processing (RESPA, TRID)
Desktop Underwriting (DU), Automated Underwriting System (AUS)
FHA & VA Loan Requirements
Project & Process Management:
Quality Management
Project Management
Process Improvement
Strategic Planning
Leadership & Team Training
Software Proficiency:
MS Office Suite (Advanced)
H2O Online, Enterprise Appeal Application (EAA), Innovalon
Claims Management Systems (list specific systems if possible, eg, "Claims System X," "System Y")
CCMS, RxClaim, EPIC, Finesse Agent, QNXT, Care Manager
CRM Systems (specify if possible), ACS/SIR, JURIS/TAMS2
Telnet-Shiva, VSI-Fax, PHR Help Tool, Active Advice 103
Disability Claims System (DCS), Enterprise Content Management (ECM), SharePoint
Medical Terminology:
ICD-10 & CPT Codes
Awards
ExCEED Award 2006, Aetna Disability & Absence Management
Remarkable Effort Award 2005, Aetna Disability & Absence Management
Timeline
Benefit Specialist
Dearborn Group
09.2023 - Current
Disability Claims Manager
Jacobson Group (Insurance Staffers, Inc)
07.2021 - 12.2022
Direct to Consumer Loan Processor
Caliber Home Loans
10.2020 - 07.2021
Claims Adjuster
Combined Insurance – Chubb Company
11.2018 - 10.2020
Quality Review Analyst
Aerotek Contract - Blue Cross Blue Shield HCSC
08.2018 - 11.2018
HEDIS Clerk II
Aerotek Contract - Blue Cross Blue Shield HCSC
01.2018 - 05.2018
Care Senior Associate, Health Services Department
Cigna HealthSpring - Managed Care Organization
01.2016 - 01.2018
Sr. Disability Representative
Sedgwick CMS
07.2010 - 01.2016
FMLA Specialist I
Sedgwick CMS
01.2010 - 01.2011
Customer Service Advocate
Aetna Inc. (Active Health Management)
07.2007 - 07.2010
Family Medical Leave Act (FMLA) Coordinator
Aetna Disability & Absence Management (Formerly Broadspire)
07.2006 - 07.2007
Administrative Support
Aetna Disability & Absence Management (Formerly Broadspire)
07.2004 - 07.2006
Bachelor of Arts - Human Resource Management
University of Phoenix
05.2001 -
Associate of Arts - Graphic Design/Multimedia
Westwood College
05.2001 -