Experience

Next Level Administrators, LLC

• United States
• Claims Adjusting, Actuarial Services
• 1 - 100 Employee

• Sr. Workers' Compensation Adjuster

  • Oct 2020 - Present

  • Thoroughly investigate workers’ compensation claims by contacting injured workers, witnesses, medical providers, and employer representatives. • Determine if claims are valid under applicable workers’ compensation statues. • Communicate with medical providers to develop and authorize appropriate treatment plans • Review and analyze medical bills to confirm charges and treatment plan • Ensure appropriate payment medical treatment, litigation fees, and benefits to (temporary permanent disability benefits) to the injured worker • Consult with attorneys regarding litigation management, settlement strategy and claim resolution • Participate in regular client (POE) claim file reviews, Show less



AmTrust Financial Services, Inc.

• United States
• Insurance
• 700 & Above Employee

• Sr. Workers Compensation Adjuster

  • May 2011 - Sep 2020

  • Provide customer services by returning telephone calls, responding to email and written correspondence. • Determine and resolve issues of insurance coverage, compensability, and liability, in order accept, delay, or deny claims within the statutory time constraints. • Administer benefits of temporary disability, permanent disability, vocational rehabilitation benefits and medical treatment in compliance with California State Workers’ Compensation Laws, Federal Laws and company guidelines. • Prepare claims defense to mitigate liability by effectively using defense medical evaluations, QME’s, AME’s, and investigations • Review all files on a 30-day diary system to address reserves, mail, issue identification strategy, development, follow-up with proactive action plans. • Participate in negotiation process by attending hearings and providing deposition and testimony to ensure cost effective resolution of each claim. • Conduct regular claim review with insured clients and brokers. Show less



Essential Staffing Professionals, Inc.

• Staffing and Recruiting
• 1 - 100 Employee

• Workers' Compensation Adjuster

  • Jan 2010 - May 2011

  • Actively manage caseload of Workers’ Compensation, liens, medical only and future medical care claims. • Manage diary and complete task to ensure that claims move toward best proactive for timely resolution. • Analyze and update coverage and reserve requirements • Ensure excellent and timely communication with clients, insureds, medical providers, attorneys, and claimants to move claim towards resolution. • Processing of all incoming correspondence, emails, and telephone calls. • Actively manage caseload of Workers’ Compensation, liens, medical only and future medical care claims. • Manage diary and complete task to ensure that claims move toward best proactive for timely resolution. • Analyze and update coverage and reserve requirements • Ensure excellent and timely communication with clients, insureds, medical providers, attorneys, and claimants to move claim towards resolution. • Processing of all incoming correspondence, emails, and telephone calls.



Westaff (USA) Inc. .

• Walnut Creek, California

• Workers’ Compensation Claims Analyst

  • Jul 2007 - Dec 2009

  • Maintain an active diary of all active indemnity claims • Coordinate case resolutions and strategy plans with all parties involved. (Insurance carrier/TPA, Legal Counsel), • Monitor claims on a case by case basis via Insurance Carrier/TPA’s on-line system • Manage a panel of legal counsel, industrial clinics, and approved special investigation vendors. • Conduct field offices training on workers’ compensation systems, procedures, guidelines, and documentation (RU91, DWC-1, Etc…) • Communicate with Risk Analyst and Safety Manager on key areas affecting those parts of the program • Assist the field offices with unique or problematic claim situations • Work closely with our Insurance Carrier/TPA medical case management staff to develop and implement early intervention on medical case management programs Show less



Travelers

• United States
• Insurance
• 700 & Above Employee

• Workers' Compensation Claims Adjuster

  • Jan 2004 - Feb 2007

  • Conduct AOE/COE investigation of claims by obtaining statements from the parties involved, obtaining outside expert opinions (medical, legal, police, loss prevention & engineering) and obtain/reviewing medical records• Determine compensability in a timely manner while carefully reviewing information gathered through the investigation process and applying the Worker’s Compensation Laws of the State of California.• Consistently comply with SHI instructions (insured contracts), communicating frequently with insured, providing reports, advisories, maintaining quality claim files, accurate estimates and claim management strategies.• Provide claim file information to legal department on litigated claims in order to appropriately coordinate resolution strategy• Create weekly and/or monthly statistical reports for all insured, or management as required.• Administer payments (permanent/temporary disability benefits), medical bills, transportation costs, litigation fees, and interpreter fees. Show less

• Notice Of Loss Coordinator

  • Mar 2002 - Jan 2004

  • Promptly review all new notices of loss/injury to identify (policy coverage, compensability and causal relatedness issues, potential fraud, catastrophic injuries, subrogation and apportionment)• Electronically assign all new notices of loss to appropriate claim adjuster based upon the characteristics of the claim, anticipated complexity, and case severity.• Accurately maintain matrix to reflect up to date insured accounts and assigned claims adjusters Performed monthly analysis of departmental expenses reporting differences in actual expenses versus budget.• Identify and resolve processing discrepancies (file transfers) Show less

• Claim Assistant/Customer Service Representative

  • May 2000 - Mar 2002

  • Setting up claim files, contacting medical facilities to set up appointments, and dairying files.• Paying bills and screen financials for duplicate payments • Provide support to claim handlers by photocopying and processing assigned activities on claim files• Receive and address customer inquires in a call center environment