Rosana Gonzalez

510-***-****

ad330q@r.postjobfree.com

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Claims Assistant

Workers Compensation Administration Investigations A dedicated professional with four years Assistant Claims Examiner experience in Worker’s Compensation, exceptional customer service, financial skills, and a strong work ethic. Self-motivated/dedicated professional with extensive experience providing support in professional business environments requiring a high level of responsibility to include managing details, customer support, quality assurance, attention to detail, organization, multiple tasks simultaneously, project and assignment follow- through. Demonstrate insurance claim expertise, report writing, strong interpersonal/verbal communication abilities with internal/external customers, healthcare providers and team members. Strong project management skills; including thorough knowledge and complete follow-up to all time sensitive issues.

Bi-lingual in Spanish

Union Experience

Research/Problem Resolution

Worker’s Compensation laws

Report Compilation/Distribution

Medical/Legal Terminology

HIPPA Protocols/Standards

Financial Software

Staff Training and Mentoring

Technical proficiencies: Anthem Blue Cross online, Call Center ACD/IVR, HEALTHsuite, Diamond, Image Right, Ana Claims, Argus, Juris SIR, ClaimsConnect, Perform Rx, TrueCare, CoreCare and Interhub software programs. Microsoft Office Suite: Microsoft Word, outlook, Excel, and PowerPoint.

PROFESSIONAL EXPERIENCE

LABORERS FUNDS ADMINISTRATIVE OFFICE OF NORTHERN CALIFORNIA, INC. Pleasanton, CA 5/2023 – 10/2023 Benefits Specialist

Provided administrative/customer service support to members, and a single point of contact for the Benefits Division, where all questions/needs were addressed. Decreased wait time, eliminated unnecessary call transfers, and provided an efficient, friendly, quality customer experience.

Progressive knowledge of Defined benefits/contributions plans, enrollments, processing health claims, pension benefit payout processing/retiree maintenance, annuity benefit payout and vacation benefit payout processing. MERRIWETHER AND WILLIAMS INSURANCE SERVICES San Francisco, CA 8/2021 – 5/2023 WC Claims Assistant; Sedgewick CMS; Contract

Maintained up to date claim information and entered bill payments for approval/issuance.

Filed and Served Documents to DA and AA

TUELL AND ASSOCIATES, INC., Alamo, CA

WC Claims Assistant; CCCSIG; Temporary 4/2021 - 07/2021

WC Claims Assistant; TriStar Risk Management; Temporary 2/2021 - 03/2021 ATHENS ADMINISTRATORS, Concord, CA 11/2018 - 01/2020 Assistant Claims Examiner/ Medical Only Examiner

Provided clerical/technical assistance to Senior Claims Examiners and administered Medical Only claims. Ensured timely processing of claims, payment of benefits, managing/directing medical treatment, and setting reserves. Calculated wage statements and adjusted disability rates, as required. Kept diary for all delay dates and indemnity payments. Processed new claims in compliance with client’s Service Agreements and issued all indemnity payments/awards on time. Prepared objection letters to providers for medical bills; delayed, denied and lacking reports. Contacted treating physician for disability status, employer for return-to-work status or availability of modified work and injured worker at initial set up. Sent DWC notices, issued SJDB Notices and Request Job Description from Employer in a timely manner.

Handled Medical Only claim files, documented file activity and updated information on computer (i.e. demographic information). Scheduled appointments for AME and QME evaluations, sent appointment letters, issued TD/mileage and medical files.

Filed and served documents on attorneys, WCAB and doctors. Served PTP’s with medical file and Duties of Treating Physician (9785) Request PD ratings from DEU Draft. Stipulated Awards and C&R’s Submit C&R, Stipulated Awards to WCAB for approval with documentation Process checks – stop payment, cancellations, void, and journal payments. Rosana Gonzalez

510-***-****

ad330q@r.postjobfree.com

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AMTRUST NORTH AMERICA, Concord, CA 12/2015 – 11/2018 WC Claims Assistant

Served as Claims Assistant providing various support functions for the Worker’s Compensation claim’s department as well as for Senior Vice President, Vice President, and Claim’s Manager. Analyze claims to determine appropriate benefits in accordance with policy provisions. Collaborated with insurance representatives and claimants to substantiate coordination of benefits order. Prepared and maintained accurate documentation to support legal subrogation claims and work compensation intervention files. Adhered fully to all HIPAA compliance guidelines.

Acted as liaison between the organization/defense attorneys to schedule training and staff development. Processed IMR’s and uploaded documentation to Maximus Federal Services’ Website. Processed 132A, Serious and Willful Misconduct Letters. Maintained client/vendor records and entered information into database while auditing for accuracy and completion. Paid vendor and temp invoices. Prepared various weekly, monthly, and quarterly reports for management with 100% attention to detail for accuracy before submitting to corporate levels. Selected Achievements:

Ordered and maintained inventories of materials, supplies and related items while initiating spreadsheet resulting in reducing the cost of supplies by over 20%.

ALAMEDA ALLIANCE FOR HEALTH, Alameda, CA

Provider Relations Representative/Claims Customer Service Representative 6/2015 – 12/2015

Corresponded to provider inquiries regarding claim information, authorization, and other issues. Collaborated with Member Services, Medical Services and Claims Departments. Accurately documented all communication with external clients, appropriately escalated any major issues and strived to discover sound resolutions quickly. Performed administrative tasks including file maintenance, report preparation and document/mail processing. Actively attended meetings and trainings. Adhered to HIPPA/confidentiality protocols. Successfully resolved numerous third-party liability cases.

Selected Achievements:

Recognized for continuously interfacing with internal/external contacts in a professional manner. Member Services Representative 3/2011 – 6/2015

Provided accurate benefit and contract information to internal/external HMO Medi-Cal Managed Health Plan customers. Prepared/submitted health insurance enrollment forms. Resolved patient health coverage issues and implemented first call resolution protocols. Clearly explained patient/physician rights and responsibilities, as well as educated members about medical center services, policies/procedures. Worked in a cooperative manner with other departmental staff to formulate solutions to member grievances/complaints. Attended department meetings/training sessions. Worked with staff to complete audits. Adhered to HIPPA protocols. Selected Achievements:

Commended with numerous "kudos" for outstanding customer service/problem solving abilities.

Received Customer Service Award in 2014.

Consistently maintained a high service level and exceeded the minimum 80% call reception rate. EDUCATION / CREDENTIALS / DESIGNATIONS

Bachelor of Science, Criminal Justice Administration. Option: Corrections California State University, East Bay Community Oriented Policing & Problem Solving (COPPS) Certified Medical Only Claims Examiner Designation

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