Manager Medical

DOROTHEA JONES

Louisville, Kentucky

Cell: 502-***-****

PROFILE

Multi-Jurisdictional Case Manager licensed in Kentucky and Indiana, have held non –resident license in

the States Illinois, Texas, South Dakota, Nevada, North Carolina, South Carolina, Georgia, Michigan and

Minnesota and Virginia. Home Health Care Associate PRN.

CORE COMPETENCIES

• Ability to prioritize multiple tasks and meet deadlines

• Excellent written and verbal skills

• Excellent customer service skills

• Medical and Legal Terminology

• Multiple state claims handling

• Microsoft Word, Excel, and PowerPoint, Outlook

• Windows, AS400 and Citrix, Risk Master, Pericura

• Knowledge of HIPPA Guidelines

PROFESSIONAL EXPERIENCE

4/13 – Present Bartech Group/Ford Motor Company

Workers Compensation Plant Rep II/Ford Motor Company

Investigates claims to determine an injured worker’s entitlement to Workers’ Compensation benefits.

Makes 3-point contact on new claims within 24 hours in order to obtain information necessary to make a

compensability decision on the claim. Works closely with injured worker, supervisors, on site plant

medical team and outside treating physicians to reduce lost time from work. Administers indemnity and

medical benefits for valid Workers’ Compensation claims. Manages a caseload of claims from inception

to closing or settlement. Establishes appropriate reserve levels based on financial exposure and updates

reserves upon receipt of new information. Identify loss trends and communicate information accordingly

to Labor and Risk Management and HR. Investigate and manage claim subrogation and negotiate

settlements. Document claim handling activities; create and document action plans to move claims toward

closure. Directs administrative assistant to properly pay indemnity benefits, Awards, and related medical.

Issue state-mandated benefit notices within the required timeframes. Address incoming mail on a daily

basis. Respond to request and questions to all parties involved in claim with response in professional

manner.

4/12 – 4/13 Collins and Company

Sr. WC Case Manager

Analyzed and managed COMPLEX difficult 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. Negotiated settlement of claims within designated authority. Set

RESERVES based on EXPOSURE to claims; manages reserve adequacy throughout the life of the claim.

Calculated and payed benefits due; approved and made timely claim payments and adjustments; settled

clams within designated authority. Prepared state fillings. Coordinated vendor referrals for additional

investigation and/or medical case management. Used appropriate cost containment techniques including

STRATEGIC VENDOR PARTNERSHIP to REDUCE overall cost of claim. Reported claims to the

EXCESS. Responded to client, customer,claim related requests in a professional and timely manner.

Communicated claim activity and process to all parties. Maintained professional client relationships.

Ensured claim files were properly documented and claim coding correct. Referred cases when

appropriate to supervisors and management.

10/11- 04/12 Insurance Recruiting Service Avizent

Sr. Case Manager

Investigated claims for medical and lost wage benefits under minimal supervision while utilizing best

practices and special account instructions. I verified available coverage, determined extent of liability

and compensability, secured recovery from third party, evaluated and established reserves with

independent and COLLABARATED judgment.

10/07 - 10/11 Cannon Cochran Management Services

Claim Representative

Investigated claims for medical and lost wage benefits under minimal supervision while utilizing best

practices and special account instructions. I verified available coverage, determined extent of liability

and compensability, secured recovery from third party, evaluated and established reserves with

independent and COLLABARATED judgment. Act as liaison for the client, injured worker, the medical

provider and attorneys. Worked with members of managed care team to evaluate and implement recovery

plan. Scheduled the IME and FCE evaluations. Referred and prepares cases for litigation. Reviewed case

law and statutes for appropriate implementation. Reviewed medical claims for appropriate reduction and

payment. Had the authority to resolve Indemnity and Subrogation claims. * Specialized handling of

State black lung claims. * Recipient of Certificate of Excellence*.

12/02 - 04/07 AP Capital Group, Louisville KY.

Sr. WC Adjuster

Investigated lost time claims under minimal supervision. determined extent of liability, compensability,

secures recovery from third party, evaluates and establishing reserves using independent judgment. Act as

liaison for the client, injured worker, the medical provider and attorneys. Collaborate with members of

managed care team to evaluate and implement recovery plan. Schedules the IME as well as FCE's.

Referred appropriate claims for litigation. Review case law and statutes for appropriate implementation.

Reviewed medical claims for appropriate reduction and payment. Within established authority to resolve

Indemnity and Subrogation claims. Assisted in continued education of claims staff by arrangement of

mini seminars with Law Firms and medical vendors. Handled over 300 run off claims during

restructuring and re-locations process from Louisville to Lansing Michigan.

7/00 - 12/02 Risk Management Services Corp. Louisville, KY

Workers Compensation Claims Representative

*Dedicated Unit Account Management: TARC and Jefferson County Fiscal Court

11/97 - 7/00 Insurance Overload Temporary Service, Louisville, KY.

Workers Compensation Claims Representative

11/81 - 11/97 The Travelers Insurance Company, Louisville, KY.

Call Center Operator/ Claims Coordinator/Case Manager

As a call center operator I was solely responsible for manually documenting incoming automobile,

LIABILITY, and property losses. I assigned those losses to claims to adjusters and appraisers. I

performed all clerical functions in addition to maintaining a SUBROGATION log. When promoted to a

Claims Coordinator, I assisted claim adjusters in the property casualty department with all clerical

functions and prepared documents for STATE FILING. In 1992 I was promoted to Claims Adjuster in

The Workers Compensation Department. I obtaine-d the Independent Adjusters license while

simultaneously through a home study course through The American Education Institute obtained a

Certificate for Workers Compensation Claims Law Associate as well as a Certificate in Medical

Terminology. I was Awarded The Travelers of Outstanding Achievement Award. for $800,000.00

recovery in Subrogation monies in a single year.

EDUCATION

• Sullivan University, Louisville, KY., A.A.S Paralegal

• Kentucky Healthcare Institute, CNA Training

• Independent Adjusters Training, Atlanta, GA.

• Attends various jurisdictional focused seminars quarterly

• Watterson College, Louisville, KY.

• Southern High School, Louisville, KY.

PROFESSIONAL DESIGNATIONS

• Commonwealth of Kentucky Licensed Independent Adjuster

• Certified Healthcare Professional

• CPR Certification, American Red Cross

• AEI WC Claims Law Associate

• Medical Terminology Certificate

• Clerical Support Specialist

COMMUNITY SERVICE

The YMCA Boys & Girls Club, Girl Scouts of America, Elder Serve, The Muhammad Ali Center

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