Senior Worker’s Compensation Claims Specialist at CCMSI

• Sep 2020 - Present

Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution. Negotiates settlement of claims within designated authority. Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim. Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level. Prepares necessary state fillings within statutory limits. Manages the litigation process; ensures timely and cost effective claims resolution. Coordinates vendor referrals for additional investigation and/or litigation management. Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients. Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets. Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner. Communicates claim activity and processing with the claimant and the client; maintains professional client relationships. Ensures claim files are properly documented and claims coding is correct. Refers cases as appropriate to supervisor and management. Show less

Claims Examiner II

• Jul 2019 - Sep 2020

Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution. Negotiates settlement of claims within designated authority. Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim. Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level. Prepares necessary state fillings within statutory limits. Manages the litigation process; ensures timely and cost effective claims resolution. Coordinates vendor referrals for additional investigation and/or litigation management. Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients. Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets. Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner. Communicates claim activity and processing with the claimant and the client; maintains professional client relationships. Ensures claim files are properly documented and claims coding is correct. Refers cases as appropriate to supervisor and management. Show less

• Feb 2017 - Jul 2019

• Sep 2016 - Feb 2017

Investigate claims by interviewing employee, employer, and physicians. Determine compensability Monitor medical treatment in conjunction with Medical Management personnelPromptly approve medical bills for paymentCoordinate light duty availability with medical providers and employersReview any assigned impairment rating for accuracy and either transfer claim timely. Convey positive attitude and team spirit for optimum provision of services to customersAttend client meetings as necessary Maintain reminder requirements Maintain work flow requirementsDetermine subrogation potential, document recover screen and pursue recover where applicable Report to client when required either per account instructions or as warranted by claim circumstances or directed by SupervisorMaintain claim closure ration of at least 97%Maintain required CEU credits Show less

• Apr 2014 - Sep 2016

Verify coverage, investigate, manage and resolve medical only claims promptly and accuratelySets up new claims in system and paper files, ensuring all documentation is present and correct.Prepares, schedules and processes benefit and medical payments on claim files as directed by the Claims Examiner.Calculate and pay Wage Loss benefitsDocuments all work product and claim activity in the electronic claim file.Prepare, schedules and processes Prepares and prints letters, benefit notices and labelsCleric Support Provides clerical support, including filing, faxing, sorting, and alphabetizing. Communicates pertinent claim information to the client, legal counsel, medical and rehab providers and internal claims staff.Answers phone calls, take messages and responds appropriately.Performs receptionist duties on a back-up basis. Show less

Supervisor

• Jan 2010 - Apr 2014

Orient & Train new and current employees Assign work Resolve complaints Evaluate Performance Create Spreadsheets Preparing files Data Entry Set up appointments for new patients Send out authorizations request for Surgery, MRI, X-rays ect Call and Verify Eligibility with Insurance for patients. Customer Service Orient & Train new and current employees Assign work Resolve complaints Evaluate Performance Create Spreadsheets Preparing files Data Entry Set up appointments for new patients Send out authorizations request for Surgery, MRI, X-rays ect Call and Verify Eligibility with Insurance for patients. Customer Service

Secretary

• Jul 2008 - Oct 2009

Screen and direct all incoming calls Accept, sign for and log all packages. Distribute to appropriate staff Open , sort and date stamp and distribute incoming mail and distribute on daily basis Create Spreadsheets Support Management and other general duties Documentation retrieval Preparing files for submission Keeping clients up to date on the status of all outstanding loan modification files Extensive follow-up (lender) Data Entry Sent Fed Ex packages when needed Screen and direct all incoming calls Accept, sign for and log all packages. Distribute to appropriate staff Open , sort and date stamp and distribute incoming mail and distribute on daily basis Create Spreadsheets Support Management and other general duties Documentation retrieval Preparing files for submission Keeping clients up to date on the status of all outstanding loan modification files Extensive follow-up (lender) Data Entry Sent Fed Ex packages when needed

Administrative Assistant

• Jan 2007 - Jun 2008

Screen and direct all incoming calls Accept, sign for and log all packages. Distribute to appropriate staff Ordering office supplies (ie: copy paper, toners, FedEx supplies, business cards, Stationery) Ordering medical supplies Prepare purchase orders for supplies and place online-order Negotiate best offer when purchasing items for clinic with rep. Arranging lunch meetings for Doctors and staff when needed Open , sort and date stamp and distribute incoming mail and distribute on daily basis Create spreadsheets Support Management and other general duties Review time sheets Data Entry Customer Service Show less