Responsibilities
Carol Lapetina has direct contact with the account team, clients, and claims administrator staff – often under stressful circumstances. The Audit Manager position is particularly challenging, as it demands that the auditor quickly master the operations and processing systems at a Claims Administrator (claims processing; eligibility; provider maintenance; pricing database), in order to evaluate in depth the claims adjudication for a specific client, and to challenge the Claims Administrator where an adjudication outcome seems to be at variance with plan design or industry standards – or fails to meet the test of “reasonableness.” Carol also manages the Dependent Eligibility Audit team, which facilitates dependent eligibility/verification and working spouse audits and responds to member inquiries regarding the audits.
Background
Prior to managing and conducting claim audits, Carol managed the Member Advocacy Team at Conner Strong & Buckelew for more than ten years. The Advocacy team acts as a liaison between the Claims Administrators and clients to resolve employee/member claim issues and billing inquiries, provide assistance with medical and prescription pre-certifications, and conduct benefit provision research when required. This function involves handling the most-complex medical claim scenarios for which plan members have sought assistance from an independent party, typically when the Claims Administrator has been unable to provide a solution.
Carol’s frontline experience with member claim issues, coupled with her hands-on approach and problem-solving skills developed over 35 years in the insurance industry, has made her a very effective medical claims Audit Manager and auditor. She is able to mediate the often-conflicting viewpoints of the Claims Administrator, the claimant, and the Plan Sponsor, always cognizant of what the medical plan intends and what it can provide.
Professional Designations
NJ Licensed in Property, Casualty, Life, and Health Insurance
Certified Insurance Service Representative (CISR)
Certified Professional Coder (CPC)
