Claims Adjuster Specialist

DONNA E. JEFFREY

*** ***** *** *****, ********** NC 27546 304-***-**** cell (Email: *********@****.***)

Professional Summary

Highly motivated and hardworking WC Claims Adjuster of over nine (9) years, and with more than thirty-one (33) years in the legal field specializing in workers’ compensation.

Skills

Strong Work Ethic; Proficient in MS Office; Strong Research and Investigation Skills; Strong Organizational Skills; Some experience in EDI filing.

Work History

Workers' Compensation Claims Specialist 06/2023 to present – CorVel Corporation, P.O. Box 77880, Charlotte, NC 28271 Investigate claims (medical only & lost time) for TPA as claims specialist/adjuster in (NC) through three (3) point contacts to collect information regarding injury; Establish and adjust claim reserves as required; Determine authorization or denials for medical treatment; Diary all claims for important deadlines and respond to supervisor’s deadlines; Explain process to injured workers; Review tasks/emails/diaries daily in order to process all medical invoices for payment; continuously update computer system with incoming claims documents and emails; Establish the necessity for TTD or TPD benefits; Send, review, and calculate AWW/CR; Process TTD and TPD benefit payments; Coordinate and communicate with NCM regarding medical treatment and to assist injured workers in return to work; litigate claims with our defense counsel and injured workers’ attorney, Coordinate and communicate with various vendors as needed. Respond to all calls, emails, and faxes from various parties.

Workers' Compensation Claims Adjuster II 10/2016 to 06/2023 - Builders Mutual Insurance Company, 5580 Centerview Drive, Raleigh NC 27606 Investigate claims (medical only) for over one year as an in-house adjuster in various states (Med Only - MD, VA, GA, NC, TN, MS, and FL), then over 6 years as (Lost Time – MD) through three (3) point contacts to collect information regarding injury; Determine compensability; Establish and adjust claim reserves as required; Diary all claims for important deadlines and respond to supervisor’s deadlines; Explain process to injured workers; Take recorded statements of Claimant’s with back or head injuries, as well as for possible denied claims; Review tasks/emails/diaries daily in order to process all medical invoices for payment; continuously update computer system with incoming claims documents and emails; Establish the necessity for TTD or TPD benefits; Send, review, and calculate AWW/CR; Process TTD and TPD benefit payments; Coordinate and communicate with NCM regarding medical treatment and to assist injured workers in return to work; litigate claims with our defense counsel and injured workers’ attorney, coordinate vocational rehabilitation for eligible injured workers’, negotiate settlement/clinchers of claims with PPD rating, Medical Cost Projections, and Medicare Set Aside. Coordinate and communicate with various vendors as needed. Respond to all calls, emails, and faxes from various parties.

Workers' Compensation Adjuster 11/2015 to 10/2016

Brentwood Services Administration/First Benefits Insurance Mutual, 209 Fayetteville St, Raleigh NC 27604

Investigate NC injury claims (medical only & lost time) for TPA through three (3) point contacts to collect information regarding injury; Determine compensability; Establish and adjust claim reserves as required; Diary all claims for important deadlines and respond to supervisor’s deadlines; Explain process to Claimant’s; Take recorded statements of Claimant with back or head injuries, as well as possible denial claims; Continuously update computer system regarding claims; File the necessary forms with the IC; Review and process all medical invoices for payment; Establish the necessity for TTD or TPD benefits; Send, review, and calculate AWW/CR from Form 22; Process TTD and TPD benefit payments; Coordinate and communicate with TCM and NCM regarding medical treatment and to assist employees in the return to work; Prepare 607 packets for Claimants with counsel; Negotiate settlement for cases with 25R for possible clincher and closing, not just payment of PPI rating; Respond to all calls, emails, and faxes from various parties.

Workers' Compensation Adjuster 02/2014 to 09/2015

Cape Fear Valley Medical Center 1638 Owen Drive, Fayetteville NC 28304

Investigate claims (medical only & lost time) for Employer by contacting employees, supervisors, and other witnesses to collect information regarding incidents; Explain process to employees/IW; Collect medical data; Determine case compensable; Interact with external people such as attorneys, physicians, and other parties to coordinate mediations, settlement and processing of claims. Establish and adjust claims reserves as required. Coordinate with nurse case manager and vocational rehabilitation professionals, to assist employees in the return to work. Negotiate settlement for cases falling within established guidelines; Assist our legal counsel in the preparation of materials and evidence for use in NC Commission hearings. File forms to the NC Industrial Commission by designated deadlines.

Workers’ Compensation Paralegal 05/2004 to 12/2013

Jackson Kelly, PLLC- 1600 Laidley Tower, PO Box 553, Charleston WV 25322

Assist multiple attorneys, independently, and directly with clients at office and job sites. Duties consist of updates on various database programs, requesting and organizing medical records, preparing medical summaries and medical packets for IME's.

Workers’ Compensation Paralegal, EP Claims Deputy, Hearings Examiner 03/1992 to 05/2004

WV Workers' Compensation Office of Judges -1 Players Club Drive, Charleston WV 25328

Prepare hearing dockets; abstracting claims and drafting orders; Two years later -EPCD, drafting written ALJ Decisions and Orders; Six years later – HE, public position representing the OOJ as a Non-Attorney Adjudicator.

Education

Active NC Adjusters License (NPN# 17293847) Also licensed in NC, SC, GA, MS, TN, and FL. Designations: CBIA

Associate of Arts: Paralegal Studies

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