CAREER Success oriented, with over ** years of exceptional
experience in claims representation.
SUMMARY: Looking for a career advancement to combine Workers
Compensation and claim handling skills obtained through on the job
assignments as well as advanced certifications. Having a strong
sense of responsibility, self-motivation and outstanding talents
for assessing client's needs, I'm an excellent team player, with
the ability to work independently, in a highly professional and
diplomatic manner to effectively communicate with all levels of
management.
WORK
EXPERIENCE:
CGI Federal
Cleveland, OH
Medical Claims Specialist
02/13- Present
*Follow up on Center for Medicare Service leads for claims
that should have been paid by another payer
* Confirm correct primary payer insurer for claim
* Initiate a demand process with insurance companies
including evaluation of beneficiary information.
* Track correspondence through to ensure timely response
within Service Level Agreements.
* Facilitate and document communication with both insurers
and employer groups.
* Provide accurate and timely responses to queries through
multiple comminication outlets.
* Escalate outlying queries that have unique circumstances
to supervisors in alignment with prescribed processes.
Baylor and Associates
Brecksville, OH
Claims Administrator
05/08 - 03/12
* Interpret and implement State of Ohio Law and Bureau of
Workers' Compensation (BWC) policies, to clients, to establish
claims.
* Process 1099 for Self-Insured employers.
* File SI-40 (Paid Compensation and Case Reserves) for Self-
Insured employers.
* Negotiate settlements with attorneys on Medical and Indemnity
claims.
- Ranging from $1000.00- $90,000.00
* Process Environmental Exposure Claims.
* Create Loss Run Reports to illustrate claim pay out amounts
and reserves for future cost.
* File court appeals to BWC, District and Staff Hearing
Officers.
* Schedule Independent Medical, Permanent Total Disability, 90-
Day and Percentage Partial Examinations.
* Pay compensation wages for Percentage Permanent Partial,
Temporary Total and Wage Loss Settlements.
* Prepare Medical Examination Letter for physicians.
* Review invoices of payment for Defense Medical.
* Input medical bills for payment into Medical Payment Systems.
* Established compensation checks drawn against awarded claims.
* Run and review audit reports for check runs.
* Create work file for check printing.
* Manage and referred compensation claims for Vocational
Rehabilitation.
* Implement reserves on compensation claims based on claim
allowance.
* Adjust reserves when unexpected treatments occur.
* Report catastrophic claim to excess insurance carrier.
* Reduce reimbursement fee bills in accordance to the BWC Fee
Schedule.
* Process and forward Certification and Denial Correspondence.
Kelly Services
Record Acquisition Coordinator
Mayfield Hts., OH
Assignment: Litigation Management Inc.
02/07 - 11/07
* Contact various medical facilities, government agencies,
insurance companies, personnel departments, educational
facilities, and the military to obtain necessary medical and
non-medical records.
* Identify medical providers from legal documents, the
internet and other resources.
* Generate request letters and initiate follow up telephone
calls.
* Review records received to ensure the completeness.
* Obtain pathology/radiology inventories.
* Working knowledge of medical terminology.
1-888-OhioComp
Cleveland, OH
Workers' Comp. Claims Specialist
07/06 - 12/06
* Contact providers for medical documentation
* Process initial injury reports
* Verify and resolve appropriateness of medical
treatment and charges.
* Gather information to develop, negotiate and
implement return-to-work plans.
* Managed on the job injury reports
* Process new worker compensation injury claims
* Enter all work data into claim system
* Follow-up with injured worker for claim
information
Insurance Overload Systems Cleveland, OH
Workers' Comp. Claims Representative
Assignment: St. Pauls Travelers
04/06 - 05/06
Assignment: GAB Robbins 05/05
- 09/05
Assignment: Specialty Risk Service
07/04 - 01/05
* Communicate with outside workers'
compensation representatives to ensure timely
processing and response.
* Conduct medical inquires with doctors to obtain
information to accurately assess claims.
* Perform claim maintenance and establish contact
with all interested parties.
Brown and Margolius Law Offices
Cleveland, OH
Claims Assistance
10/03 - 02/04
Temporary Contract
* Analyze files and applications for proper
adjustments.
* Process 1st report of injury forms and document
all medical claims and forms.
* Forward legal documentation and representation on behalf
of clients.
Bureau of Workers' Compensation Cleveland,
OH
Customer Service Specialist
03/79 - 02/02
* Change Caseload of Workers' Compensation Lost-Time
Disability Claims.
* Make decisions for claims to survivors of the deceased covered
workers who are entitled to file claims for survivor benefits.
* Verify and resolve appropriateness of medical
treatment and charges.
* Gather information to develop, negotiate and
implement return to-work plans.
* Examine illness and survivor claims.
* Research, and authorize, negotiate, and issues
settlement of claim.
* Conduct field inquires required to obtain
information to accurately assess claim.
* Resolve disputed issues to determine compensation
and appropriate benefit level.
* Identify and refer cases to fraud.
* Establish and maintain contact with all
interested parties.
* Document all claim transactions and activity in
claims diary system.
* Complete progress reports and prepares claims for
hearings with Industrial Commission.