Experience

Method Workers' Comp

• United States
• Insurance
• 100 - 200 Employee

• Senior Claims Examiner

  • Jun 2022 - Present

  Establish contact with employer to review issues, Respond to inquiries from the employer, employee, doctors and attorneys, Establish and maintain appropriate reserves, Review legal correspondence and medical reports, Evaluate and approve medical procedures and treatment, Administer benefits and ensure appropriateness of all payments, Investigate coverage, liability and monetary value of claim, Review medical and legal bills for appropriateness, Discuss appropriateness of medical treatment with medical case manager, Determine compensability, Monitor and assist litigation, Negotiate settlement of claim, liens, rehabilitation plans, etc., Prepare and present reports to clients, Appropriately close claims. Help resolve client billing and payment inquiries, Investigate complaints from injured workers, Document and code the claim files and claims system with all relevant information, Maintain and update action plans within specified time frames, Provide direction to Claims Assistants and Claims Technicians and assist with training, coaching, and mentoring as needed for them to support daily claims tasks, Contact with employers, employees, attorneys, doctors, vendors and other parties, Provide customer service and support to clients and claimants, Work collaboratively with attorneys to draft settlements and assist with litigation strategies, Negotiate settlements, Authorize and negotiate cost of medical treatment and supplies, Internal communication with staff, Prepare professional, well written correspondence and other communications. Show less


CCMSI
• United States
• Insurance
• 700 & Above Employee
• Senior Claims Examiner

  • Jan 2022 - Jun 2022


Broadspire

• United States
• Insurance
• 700 & Above Employee

• Senior Claims Adjuster

  • Jul 2021 - Jan 2022

  Establish contact with employer to review issues, Respond to inquiries from the employer, employee, doctors and attorneys, Establish and maintain appropriate reserves, Review legal correspondence and medical reports, Evaluate and approve medical procedures and treatment, Administer benefits and ensure appropriateness of all payments, Investigate coverage, liability and monetary value of claim, Review medical and legal bills for appropriateness, Discuss appropriateness of medical treatment with medical case manager, Determine compensability, Monitor and assist litigation, Negotiate settlement of claim, liens, rehabilitation plans, etc., Prepare and present reports to clients, Appropriately close claims. Help resolve client billing and payment inquiries, Investigate complaints from injured workers, Document and code the claim files and claims system with all relevant information, Maintain and update action plans within specified time frames, Provide direction to Claims Assistants and Claims Technicians and assist with training, coaching, and mentoring as needed for them to support daily claims tasks, Contact with employers, employees, attorneys, doctors, vendors and other parties, Provide customer service and support to clients and claimants, Work collaboratively with attorneys to draft settlements and assist with litigation strategies, Negotiate settlements, Authorize and negotiate cost of medical treatment and supplies, Internal communication with staff, Prepare professional, well written correspondence and other communications. Show less



Athens Administrators

• United States
• Insurance
• 200 - 300 Employee

• WC Claim Examiner

  • Mar 2018 - Jul 2021

  Establish contact with employer to review issues, Respond to inquiries from the employer, employee, doctors and attorneys, Establish and maintain appropriate reserves, Review legal correspondence and medical reports, Evaluate and approve medical procedures and treatment, Administer benefits and ensure appropriateness of all payments, Investigate coverage, liability and monetary value of claim, Review medical and legal bills for appropriateness, Discuss appropriateness of medical treatment with medical case manager, Determine compensability, Monitor and assist litigation, Negotiate settlement of claim, liens, rehabilitation plans, etc., Prepare and present reports to clients, Appropriately close claims. Help resolve client billing and payment inquiries, Investigate complaints from injured workers, Document and code the claim files and claims system with all relevant information, Maintain and update action plans within specified time frames, Provide direction to Claims Assistants and Claims Technicians and assist with training, coaching, and mentoring as needed for them to support daily claims tasks, Contact with employers, employees, attorneys, doctors, vendors and other parties, Provide customer service and support to clients and claimants, Work collaboratively with attorneys to draft settlements and assist with litigation strategies, Negotiate settlements, Authorize and negotiate cost of medical treatment and supplies, Internal communication with staff, Prepare professional, well written correspondence and other communications. Show less

• Future Medical Claim Workers' Compensation Examiner

  • Mar 2016 - Mar 2018

  Adjust workers compensation future medical claims, ensure timely processing of claims and payment of benefits, managing and directing medical treatment, and negotiating settlements. Incumbent must have the skills, ability and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation: Review daily diary for claim status Review medical reports to determine whether additional medical opinions are needed Calculate and maintain appropriate reserve on each file in accordance with life expectancy Object to unauthorized medical treatment Establish contact with employer to review issues Respond to inquiries from the employer, employee, doctors and attorneys Review legal correspondence and medical reports Evaluate and approve medical procedures and treatment Administer benefits and ensure appropriateness of all payments Review medical and legal bills for appropriateness Discuss appropriateness of medical treatment with medical case manager Negotiate settlement of claim, liens, etc. Prepare and present reports to clients Close claims appropriately Help resolve client billing and payment inquiries Investigate complaints from injured workers Document and code the claim files and claims system with all relevant information Maintain and update action plans within specified time frames Provide customer service and support to clients and claimants work collaboratively with attorneys Authorize and negotiate cost of medical treatment and supplies Show less

• WC Assistant /Medical only Examiner

  • Aug 2013 - Mar 2016

  Provide clerical and technical assistance to Senior Claims Examiners and administer Medical Only claims, ensuring timely processing of claims and payment of benefits, managing and directing medical treatment, and setting reserves , Draft Stipulated Awards and C&R's • Submit C&R, Stipulated Awards to WCAB for approval with documentation • Process checks – stop payment, cancellations, void, journal payments • Handle telephone calls for examiner as needed • Complete penalty calculations and prepare penalty worksheets • Complete MPN,HCO and/or EDI coding • Complete referrals to investigators • Complete preparation of documents for overnight delivery • Work collaboratively with Senior Claims Examiners, Nurse Case Managers and other Assistant Claims Examiners • Contact with clients, injured workers, attorneys, doctors, vendors and other parties • Provide updates of claims status to Senior Claims Examiners and Athens managemen r without reasonable accommodation: • Process new claims in compliance with client’s Service Agreement • Issue all indemnity payments and awards on time • Process all approved provider bills timely • Prepare objection letters to providers for medical bills; delayed, denied, lacking reports. • Answer questions over the phone from medical providers regarding bills • Contact treating physician for disability status • Contact employer for return to work status or availability of modified work. • Contact injured worker at initial set up • Send DWC notices timely • Issue SJDB Notices timely • Request Job Description from Employer • Handle Medical Only claim files • Calculate wage statements and adjust disability rates as required • Keep diary for all delay dates and indemnity payments • Documents file activity on computer • Update information on computer, i.e. address changes, etc. • Schedule appointments for AME, QME evaluations • Send appointment letters, issue TD/mileage, send medical file • Schedule interpreter for appointments, depositions etc Show less



Ecology Auto Parts

• Transportation/Trucking/Railroad
• 1 - 100 Employee

• Workers Compensation Administrator

  • Nov 2011 - Jul 2013

  : Investigate all employee injuries, obtain statements and follow up on medical appointments. Consult with management in order to determine if injury is considered 1St Aid or reportable. Reporting injuries to insurance company coordinate with adjuster regarding modified duty status or Return to work. Responding to inquiries from adjusters. Maintain the workers compensation files up to date(file). Coordinate with the supervisor the start and end of modified duty assignments. Explain the Workers compensation process to the injured workers and maintain contact with them to ensure they are satisfy with the treatment and any questions they might have .Arrange for witnesses require by Defense Counsel. Attend Accident and Injury review meetings and provide information on injuries as needed. Maintain the 300 OSHA logs for all companies up to date. Maintain the Injuries Report spreadsheet and TD report spreadsheet with the current information and distributing the spreadsheet reports to its recipients (managers, supervisors, etc.) Show less



Sunrise Healthcare

• India
• Medical Equipment Manufacturing

• Workers Compensation Coordinator

  • Aug 2010 - Aug 2011

  obtaining treatment/procedure authorizations from either employer or insurance company setting up new patients, faxing, filing, customer service, scheduling. Providing status calls to insurance carriers, adjuster’s, nurse case managers for intake and appointment scheduling, data entry or intake into computer software, communicating case particulars to providers, clinical staff and case managers, daily correspondence including: incoming and returned mail, correspondence from Insurance Carriers/patients/facilities, verification of insurance benefits, maintain accurate and complete notes on patients accounts, develop and maintain organized follow up and call back system, recording of daily accounts activities(supplied to and approved by management) any additional action necessary in order to accommodate patients, providers, clients, adjusters colleagues and management. Assisting Specialists with patients, proofreading dictated reports. Any necessary data entry, tracking, etc., working daily work flow task lists, contributes to team effort and accomplishing related results as needed Show less



SeaBright Insurance Company

• Workers Compensation Claims Assistant

  • Aug 2005 - Apr 2010

  assist examiner with clerical functions and benefit payments. Responsibilities include contacting the employer, medical provider and injured worker to aide in the investigation of new losses and well as to ensure timely benefits. Manage/maintain claims diaries for benefit payments as well as contact calls to physician offices for follow up evaluation status. Set up QME’s, AME’s and calendaring, maintenance of diary system, scheduling depositions, medical exams and court hearings. Effectively gather and prepare information for claims examiner to issue benefit checks, complete state benefit notices, state forms (disability, C&R, Stipulations) and assist with medical correspondence. Prepare and maintain claim file and documents, efficiently fields communications to claims examiner, redirect or solve calls as appropriate or provide clear detailed information to enhance the examiner’s ability to respond to the inquiry. Assist front office including phones, distribution of mail, paying of offices invoices, ordering supplies, assist Medical Only examiner with two point initial contact calls and set file diaries for follow up communication. Help with special projects and task as needed. Supports customer service by responding to inquiries, maintains quality service by following organization standards, protects operations by keeping claims information confidential. Knowledge of claim set up specified limit by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter, preparing files for attorney referrals, arranging flight /ground transportation and interpretation. Show less



Healthpointe

• United States
• Medical Practices
• 1 - 100 Employee

• Workers Compensation Coordinator

  • Jun 2002 - Aug 2005

  providing medical status to employer/insurance company, obtaining treatment/procedure authorizations, setting up new patients, faxing, filing, customer service, scheduling AME’s/QME’s, interpreting for the physicians when needed. Answering telephone inquiries from Insurance Carriers, Adjusters, Attorney’s Referral sources, nurse case managers, etc. for intake and appointment scheduling, data entry or intake into computer software. Ensuring accuracy of intake data, establishing and maintaining report with insurance carriers, adjusters attorneys, nursecase, managers and referral sources, coordinating with case manager’s on patient appointments and case details, communicating case particulars to providers, clinical staff and case managers, coordinating peer to peer appointments, depositions appointments, daily correspondence, including: incoming and returned mail, correspondence from Insurance Carriers/patients/facilities, verification of insurance benefits, maintain accurate and complete notes on patients accounts, develop and maintain organized follow up and call back system, recording of daily accounts activities(supplied to and approved by management) any additional action necessary in order to accommodate patients, providers, clients, adjusters colleagues and management. Any necessary date entry, tracking, etc., working daily work flow task lists, contributes to tea, effort by accomplishing related results as needed. Show less