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Click here or scroll down to respond to this candidateCandidate's Name
Workers Compensation ProfessionalMaplewood, NJ Street Address
EMAIL AVAILABLEPHONE NUMBER AVAILABLETo obtain a secure position with a reputable company that provides me with the opportunities for advancement, stability and the diversity that allows me to showcase the talent and experience gained through my career.Willing to relocate to: New York, NY - Atlanta, GA Authorized to work in the US for any employerWork ExperienceWorkers' Compensation Lost Time Claim SpecialistChubb Insurance - Jersey City, NJFebruary 2022 to Present Independently handles all aspects of workers compensation lost time claims from set-up to case closure ensuring strong customer relations are maintained throughout the process. Reviews claim and policy information to provide background for investigation. Conducts 3-part ongoing investigations, obtaining facts and taking statements as necessary, with insured, claimant and medical providers. Evaluates the facts gathered through the investigation to determine compensability of the claim. Informs insureds, claimants, and attorneys of claim denials when applicable. Prepares reports on investigation, settlements, denials of claims and evaluations of involved parties, etc. Timely administration of statutory medical and indemnity benefits throughout the life of the claim. Sets reserves within authority limits for medical, indemnity and expenses and recommends reserve changes to Team Leader throughout the life of the claim. Reviews the claim status at regular intervals and makes recommendations to Team Leader to discuss problems and remedial actions to resolve them. Prepares and submits to Team Leader unusual or possible undesirable exposures when encountered. Works with attorneys to manage hearings and litigation Controls and directs vendors, nurse case managers, telephonic cases managers and rehabilitation managers on medical management and return to work initiatives. Complies with customer service requests including Special Claims Handling procedures, file status notes and claim reviews. Files workers compensation forms and electronic data with states to ensure compliance with statutory regulations. Refers appropriate claims to subrogation and secures necessary information to ensure that recovery opportunities are maximized. Works with in-house Technical Assistants, Special Investigators, Nurse Senior Claims Examiner - ContractCrawford & Company - RemoteSeptember 2021 to December 2021Investigates, evaluates, negotiates and adjudicates first and third party claims to determine validity and verify extent of damage by telephone contact with clients, claimants, witnesses or other parties as required. Analyzes claims activity and prepares reports for clients/carriers and management. Establish reserves, using independent judgment and expertise and authorizes payments within scope of authority, settling claims in the most cost effective manner and ensuring timely issuance of disbursements.Make settlement decisions promptly and equitably and issues company drafts in payments for claims within authority limits.Develops subrogation and third party recovery potential and follows reclaim procedures. Analyzes claims activities and prepares reports for clients, carriers and/or management. Senior Claims AdministratorFoundation Risk Partners - Edison, NJJuly 2019 to September 2021Responsible for managing data extraction regarding potential Claims from fax, email or other communication sources. Examine, evaluates claims for denial, subrogation and possible fraud and report to PERM. Enter claims in system; review claims, update/correct information in system . Assign and diary for VP of Risk Management the initial action plan for case. Assist in maintaining all medical documentation and records regarding workers compensation cases Make contacts (4 point contact) with client, adjuster, employee and provider. Report claims to carrier and VP of Risk Management. Manage correspondence; answer emails and phone calls, note files. Participate in claims reviews with Client representatives when needed. Ensure all claimants complete all necessary paperwork regarding claim case, i.e. incident report, medical release form, LD forms and special programs are being carried out initially. Establish and maintain effective liaising between claimant, adjuster, provider and client. Provide VP of Risk Management with weekly/monthly overview and assurances that all services have been effective.Claims ExaminerYork Risk Services Group Inc. - Parsippany, NJOctober 2017 to June 2019Responsibilities:Investigates claims to determine an injured workers entitlement to Workers Compensation benefits in both NY and NJ; also handle losses in PA, CT, DE, ID, KY, NH, SC and UT. Administers indemnity and medical benefits for valid Workers Compensation claims; manage a caseload of claims from inception to closing or settlement. I complete 3- point contact on new claims within 24 hours in order to obtain information necessary to make a compensability decision on the claim. Establish appropriate reserve levels based on financial exposure and updates reserves upon receipt of new information. I properly pay indemnity benefits and Awards. Issue state-mandated benefit notices within the required time frames. I annotate, categorize and address incoming mail on a daily basis. Respond to questions and requests from the Client and know Workers Compensation law, policies and procedures. Claims Adjuster IIGallagher Bassett Services, Inc. - Parsippany, NJDecember 2016 to October 2017Responsibilities:Investigates, evaluates, disposes and settles the most complex claims and highest exposures with minimal supervision. Includes the investigation, determination and evaluation of coverage, liability and damages, and the setting of proper reserves. Incumbents at this level typically hold claims reserve and settlement authority of up to $10,000 liability and/or $25,000 workers compensation or greater. Exercises proper judgment and decision making to analyze the claims exposure, to determine the proper course of action and to appropriately settle the claim.Interacts extensively with various parties involved in the claim process. Able to clearly communicate concise action plans, and present plans for moving the case to conclusion. Will demonstrate complete knowledge of the claim file process through presentation of actions and responses to client questions. Processes claims consistent with clients' and corporate policies, procedures and "best practices" and also in accordance with any statutory, regulatory and ethics requirements. Demonstrated ability to comply with carrier reporting and threshold requirements. Able to recognize and pursue excess insurance recoveries. Incumbents will have the ability to handle a full case load, with proven ability to handle cases of increased severity. Knowledge of the Subrogation, Second Injury Fund, and Medicare. Jurisdictions: NY, NJ and PAClaims AdjusterSedgwick Claims Management Services - Whippany, NJ August 2016 to December 2016Responsibilities:Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency. Develops and manages workers compensation claims' action plans to resolution, coordinates return- to-work efforts, and approves claim payments. Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract. Manages subrogation of claims and negotiates settlements.Communicates claim action with claimant and client. Ensures claim files are properly documented and claims coding is correct. May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review. Maintains professional client relationships. Jurisdictions: NYPatient Relations AdvocateKindred Hospital - Dover, NJOctober 2014 to August 2016Responsibilities:I'm a liaison between patients, families, physicians and clinical staff to provide proactive and personalized services to enhance the patient and family experience. Proactively collaborates with leaders and staff to improve patient satisfaction. Proactively obtains resolution of concerns brought forward during daily rounding. Assists patients and families with the completion of the patient satisfaction survey prior to discharge.Registration CoordinatorHunterdon Medical Center - Flemington, NJAugust 2013 to May 2015Responsibilities:Arranges for the efficient and orderly registration of patients, ensures that accurate patient information is collected and that patients are made aware of hospital policies and procedures. Responsible for patient demographics utilized in the preparation of records and reports used in making operating decisions. Works with and has access to confidential patient information. Position requires making frequent decisions or actions following general procedures often without clearly defined precedents. Position requires a high degree of mental alertness and close visual attention to details. Position requires diplomacy and a professional image and manner in dealing with patients, families, and visitors. RegistrarOverlook Hospital - Union, NJAugust 2010 to May 2013Responsibilities:As a Patient Access Representative position I interview all patients in a professional and courteous manner. Completes efficient, accurate and timely registration of patient demographic information into the Hospitals computer system. This includes, but is not limited to, Inpatient, Outpatient, Emergency Room and Pre-Registration. Ensures that required insurance pre-certification, authorization and documentation is obtained for billing and medical record processing. Notifies patients of The Hospitals policies in reference to patient care. Provides excellent customer services and patient satisfaction. Performs all duties in accordance with Hospital Policy and Procedures EducationBA in Business ManagementKean University - Union, NJ2000 to 2004High school or equivalentIrvington High School - Irvington, NJSeptember 1997 to May 2000Skills I have proficient knowledge of the daily workflow of a Business Office. I am well versed in multiple computer systems Typing Data Entry. SIP Liability Data Entry Excel Microsoft Office Team Building Inventory Sales Risk Management Workers' Compensation Account Management System Administration Human ResourcesCertifications and LicensesNew York Independent Adjusters LicenseAdditional InformationI have my New York workers compensation and Auto liability insurance license. I have over fifteen years experience in the Administration/Customer Service and Sales field. Nine years medical registration. I am well versed and able to deal with multiple levels of management. Regular attendance and punctuality. Ability to professionally interact with management and coworkers. Excellent verbal and written communication skills. Strong organizational skills, multi-tasking and prioritizing capabilities. |
