Workers Compensation Claims
Resume:
Arlene Hernandez
Flowery Branch, GA 30542
C) 770-***-****
Email: *********@*****.***
Work Experience
July/2022 to Sept/2023 Biberk Insurance, Workers Compensation Lost Time Adjuster
Managed an active caseload of 125 plus files with 80% litigation from inception to close.
Responsible for handling complex accounts, working closely with Employer's to bring claims to a quick closure.
Prepare and ensure all state filings are completed and filed timely and accurately.
Ensure timely and accurate reserving in all claims.
Work closely with Employers and update them quarterly/monthly/weekly as needed on progress and closure of their claims.
Work with Defense Attorneys and or claimant's attorneys to bring claims to a quick closure.
Insure to keep the files up to standards with Audits of 85% or better
Complete Contacts with IW/Insureds on timely basis within expected 24 hours
Make appropriate referrals where applicable.
Complete Mail, legal and bills timely so they aren’t late
February 2020 to January 2022, Berkley Southeast Insurance Group - Lawrenceville, GA
Senior Claims Adjuster
Managed an active caseload of 138 files with 80% litigation from inception to close
Worked with TPA and PEO
Responsible for handling complex accounts, working closely with Employer's to bring claims to a quick closure
Prepare and assure all state filings are completed and filed timely and accurately
Ensure timely and accurate reserving in all claims
Work closely with Employers and update them quarterly/monthly/weekly as needed on progress and closure of their claims
Work with Defense Attorneys and or claimant's attorneys to bring claims to a quick closure
September 2016 to May 2019, Next Level Administrators – Bradenton, FL
Senior Claims Examiner
Managed a caseload of high-volume claims with heavy litigation
Primarily handle losses GA, FL, KY, TN, NC and SC
August 1989 to August 2017, Liberty Mutual/Summit Consulting - Gainesville, GA
Workers' Compensation Team Lead/ Senior Workers' Compensation Claims
Specialist
Workers' Compensation Team Lead/ Senior Workers' Compensation Claims Specialist
Managed an active caseload of 100-150 files with 92% litigation from inception to close
Responsible for overseeing 4 to 6 Workers' Compensation claim professionals which included litigation specialist, lost time adjusters, medical only adjusters and clerical staff
Assign new claims, authorize reserve authority, train, create a healthy team environment and mentor new employee's
Ensures all claims eligible or ineligible for payment conform to quality, production standards, and specifications
Analyzes and approves workers compensation claims
Grants settlement authority for claims
Responsible for handling complex litigated and non-litigated workers' compensation claims from inception to close; review and secure appropriate medical documentation to verify treatment and causal relationship
Primarily handle losses GA, FL, KY, TN, NC and SC
Direct the timely investigation of claims to determine the compensability of injuries/claims
File all state specific required forms in accordance with the appropriate rules
Ensure timely and accurate reserving of the claim and adjust reserves as necessary
Prepare and execute appropriate file documentation to support the need for outside services such as surveillance, rehabilitation and healthcare management and other internal searches such as ISO, and Fact el
Implement grievance process on appropriate claims in applicable states
Conduct investigation to secure essential facts from the injured worker, employer, and witnesses regarding the work comp case through telephonic and/or written reports
Verify information from injured workers, physicians and medical providers to assess continued compensability and make evaluations of all cases every 4 to 6 weeks
Recognize potential subrogation cases, prepare cases for subrogation referrals and obtain all statements and necessary information for the Subrogation Unit to follow up with
Maintain contact with injured workers and employers to ensure understanding of protocols and claims processing and/or to confirm return-to-work date; answer questions regarding the case; help educate with the protocols and state specific rules and responsibilities to both the injured worker and employer
Maintain accurate records and handles administrative responsibilities associated with processing and payment of all claims; records and updates status notes, and documents results of all contacts and relevant medical reports
Initiates and authorize payment of weekly benefits
Work with Defense Attorneys and/or Claimant's Attorneys to bring claim to closure via settlement; respond to any and all legal documentation, requests and or legal pleadings as required by rules in individual states
Currently Licensed in GA, FL, KY, NC, TN, and SC
Skills
Bilingual Spanish (Written and Verbal), MS Office Suite (Excel, Word, PowerPoint, Outlook), Lotus Notes, Windows and Mac Computers, Medical Billing, and ICD-10
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