Bilingual 620 adjuster all lines

Jeniffer M Vale, ca

Independent ALL lines adjuster 620 License

objective

Bilingual expert, experienced in ALL lines claims

management.

Active 620 FL License

Legal, Workers Compensation, Auto, Demand

adjustments.

Reserve management

Educated in Subrogation detection & mitigation

techniques

Complex claim analysis and investigations

Large loss

Public speaker, leader and educator.

Experience

Highlights of Qualifications

Creator/Moderator for Tampa Bay Gathering of the

Minds LinkedIn Group.

Six Sigma GREEN BELT

Carries out detailed claims investigations using a

range of industry approved techniques

Immense experience in claims management and

training of staff

Workers compensation, PIP Auto, Demands, Medical,

Legal & all claims adjuster

Bilingual

Ability to negotiate with internal and external

groups

Ability to complete all claim adjustments within

time frame and exceed goals.

Ability to speak publicly, educator, motivator,

leader & team builder.

12/8/2014-Present Integral Quality Care

Team project Manager

Leads team of 7 claim specialists in all aspects of

daily project operations

*This team has brought the company back up to

compliance with CMS guidelines within 3 weeks of

project start date

Supports team by conducting daily meetings in which

any questions pertaining to quality or project

development are addressed openly.

Provides coaching when appropriate in order to

ensure quality and time lines are met with

accuracy.

Ensures that team has access to all resource and

programs needed in order to complete tasks as

assigned.

Troubleshoots any issues on the floor which may

arise at any given moment then provides follow up

coaching if and when appropriate.

Keeps accurate records of project progress through

Excel MS and communicates daily with upper

management in order to address any issues and or

follow up on reports and trends.

Provides constant encouragement and motivation to

team by celebrating and recognizing their

individual successes and constantly setting new and

higher goals while adhrering to company compliance

standards.

7/8/2014- 12/5/2014 MetLife (AppleOne Project)

Settlement adjuster

MetLife Group, Voluntary & Worksite Benefits - P&C

Claims No Fault Tampa FCO

Special Project lead adjuster for MetLife class

action law suit, Loss settlement

Responsible for assessing what should be paid to

providers participating in class action law suit by

investigating PIP and Med pay payment logs in

question.

Reviewed entire provider billing history including

medicals submitted in order to accurately determine

if paid at fee schedule and what balance is

currently required to meet settlement guidelines.

Made large payments daily through restricted Linux

based program to providers once amount of final

payout is determined in order to satisfy settlement

order.

Communicated daily and effectively with management

and participates in weekly project update meetings

with MetLife Board members through conference call.

Successfully tracked project progress and

information by utilizing excel program accurately

and making information easily accessible to

everyone involved.

Recognized by management and senior leadership for

excellent quality of work throughout project

tenure.

Successfully assisted PIP department with

additional projects as assigned by management like

daily PIP claim intake and file monitoring as well

as processed all incoming Attorney and provider

Demands.

8/23/2010-5/5/2014 Aetna & Coventry merge

Senior WC Claims Administrator

Supervised, evaluated and coached employees while

delivering training, as well as provided corrective

and/or positive performance feedback as applicable.

Documented performance of Agents in training and

made recommendations to advance, terminate or

require additional training. Monitored and analyzed

ongoing performance trends in order to make

training and development recommendations. Acted as

primary training support to Agents while class is

in transition.

Delivered approved New Hire and Developmental

Training including but not limited to pertinent

legislation, Security Awareness, PHI, CMS, Systems,

Policies and Procedures, and Microsoft programs.

Delivered client approved product training using a

variety of delivery methods to keep classes fully

engaged. Demonstrated ability to teach Agents how

to clearly articulate programs to customers who

have varying ranges of understanding and/or

experience with programs. Worked with various

departments' subject matter experts as needed to

develop, enhance or update training programs,

including outlines, fact sheets, exams, and

supporting documents.

Led and/or participated in client calibration

sessions to ensure alignment of training with

client metrics. Maintained records of all training

activities, including time sheets, evaluations and

quality reviews.

Regularly communicated with the management team to

maintain product/service knowledge and ascertains

additional training needs.

8/23/2010- Coventry Healthcare

SME/Training Liaison WC claims

Actively processed all assigned escalated provider

and adjuster pre authorization requests through

various programs including web based and not

excluding Email for UR review to determine medical

necessity.

Actively communicated with providers nationally and

locally in order to gather any information missing

in order to process and complete any WC request in

a timely fashion for the claimant.

Worked regularly with Adjusters from various

national carriers in answering any questions

pertaining to any follow up required regarding any

escalated claim at any time.

Regularly assisted staff and new hires with

questions pertaining to claims received on the

floor.

Provided systems operations and work flow processes

training for new hires and current employees moving

to new accounts on the floor

Organized and created QA check for Par's to better

ensure quality.

2/9/2009-8/10/2010 Quality Health Plans

Team lead Customer Service/UM Liaison

Promoted initially from the Member services dept.

as TL at the 4 month mark after successfully

assisting supervisor in training of new hires on

the floor to support the nurses with PAR duties in

the UR dept.

Acted as liaison between health plan and all

par/none par providers in order to ensure that

members authorization requests and referrals were

processed correctly and in a timely fashion.

Created facility Authorizations pertaining to

outpatient procedures for QHP Watson Clinic and

Shands Jacksonville providers.

Managed physical evaluation requests from primary

care doctors for POV's (Power operated Vehicles) to

DME supplier until completion in order to ensure

the meeting of guidelines for UR review.

Handled all incoming calls from Hospitals to report

inpatient or member observation admissions.

Responded to Customer Service follow ups generated

through QHP internal database regarding

beneficiaries Authorizations and or not limited to

referrals.

.

Education

ADJUSTER PRO LLC

ORLANDO, FL

All lines FL resident Independent adjuster 620

License

1993-1997 Colegio La Piedad San Juan,PR

Academic Diploma

3.6 GPA

Recipient of a Gold Medal for undertaking 2 history

courses in 1 year.

NYU summer courses focusing on English Literature

and Composition.

1999-2002 UPR

University of Puerto Rico

ESL Certification through education program

Speaks and writes Spanish fluently.

Proficient in both Windows and Mac OS Systems.

Proficient in Microsoft office programs.

Contact:

Cell 813-***-**** (Anytime)

************@*****.***

https://www.linkedin.com/pub/jeniffer-

vale-ca/5a/64/b6

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