Workers Compensation Customer Service

TYLISHON SMALLS

*** ***** ***** *** *******, NC *7591 919-***-**** ******.********@*****.***

SUMMARY

Highly skilled and experienced Workers Compensation specialist with seven plus years of experience in managing and facilitating workers compensation claims. Dedicated to ensuring injured employees receive proper care and compensation while assisting employers in navigating the complex legal and administrative processes. Seeking to leverage comprehensive knowledge and proficiency in advocating for the company, employees, and employers within the workers compensation system.

SKILLS

Oral and written communication

Critical Thinking

Conflict Resolution

Team Collaboration

● World Class Customer Service

Time Management

Analytical Thinking

Diligence To Detail

EXPERIENCE

08/2022-10/2024 Claims Adjuster ll

MEMIC Ȃ Portland, ME

Managing 140 Indemnity claims for State of Maine workers compensation ensuring timely and accurate investigation while adhering to legal and state regulatory requirements.

Conduct thorough investigations to assess the validity of workers’ compensation claims, including gathering relevant information from various sources.

Evaluate claim exposure, negotiate, and resolve claims. Work closely with defense counsel on litigated cases and attend mediation, as necessary. Develop litigation plans with defense counsel and track adherence to plan to assure effective resolution.

Implement manage care strategies, coordinate rehabilitation or medical management process bills review mail through ImageRight and monitor progress as appropriate.

Effectively communicate with claimants, employers, legal representatives, and medical providers to gather necessary information and provide updates on claim status.

Maintain quality claims in accordance with best practices, company policies procedures and state workers compensation statue.

Stay informed about state and federal workers’ compensation laws and regulations, 11/2016 to 07/2018 Financial Operations Analyst

Allscripts Ȃ Raleigh, NC

Managed Northeastern region financial performance over 240 acute and pro premiere accounts equating to $51 mil in monthly revenue.

Engaged in monthly trend analysis and reporting.

Negotiated and re-mediate complex client inquiries to maintain adequate cash receipts to foster the organizations financial goals.

Engage in communication with best business practice, cross operational teams to research and resolve client inquiries.

Provided collectability analysis reports on a quarterly basis to support unmanageable debt calculations.

Maintained client relationship on Acute and ambulatory portfolio by addressing any disputes with products and Services.

Prepared key financial presentations and reports.

Maintained functions in strategic role and developed analytical metrics to improve processes, accountability, collectability, new systems, and procedures. 08/2014 to 11/2016 Associate Technical Support Consultant ensuring compliance in claims processing and maintaining up-to-date knowledge.

Work closely with other claims adjusters, management, and internal departments to facilitate a seamless claims resolution process.

07/2018 to 7/2022 Business/Billing Analyst

Allscripts Ȃ Raleigh, NC

Assist Project Managers, Financial Analyst, company Executives in implementing process improvement for tracking billing issues and root cause analysis finding corrective action resulting in increase in revenue received.

Work closely with executive management as the SMEAD on data conversion transferring information from one system to another.

Engage in internal and external client conference calls regarding billing and contract terminations.

Work closely with Sales, legal and business development team to ensure contractual terms are met on client's and company behalf.

Train and coach new hires on billing, disputes, process improvement on multimillion dollar acute accounts.

Discuss changes in internal processes and procedures to enforce execution.

Develop and implement policies to resolve outstanding balances.

Work closely with C-Level executives, sales, and business development team to promote special project success.

Executed solutions for internal process issues to streamline operations.

Write up concessions, RMAs, and open credits for Acute accounts. 01/2010 to 01/2014 Patient Financial Services Team Lead Adreima Ȃ Raleigh, NC

Managed monthly BPA Collaboration meetings on quality assurance for prerecorded calls.

Set priorities for team to ensure task completion and performance goals were met, such as productivity, Quality, and Revenue.

Conducted annual performance reviews and monitored employee's performance on departmental measurements to drive continuous improvements.

Reviewed patient accounts, back up documentation to determine the nature and extent of problem and any actions taken by patient or third-party payers.

Coordinated and supervised daily activities for business support, technical support, and production by generating pulse reports and (KPIs) to ensure department production was me

Accentuate Contractor (Allscripts) Raleigh, NC

Coordinated and supervised daily activities for business support, technical support, and production by generating pulse reports and (KPIs) to ensure department production was met.

Create cases internally to assist patients with information needed to access patient portal.

Demonstrated industry recognized best in KLAS customer service in interactions.

Maintained high first touch completion rate for medical organizations FollowMyHealth patient portal and EHR.

Communicated technical processes in unambiguous language to keep non-technical personnel informed and updated.

Documented repair processes and helped streamline procedures for future technical support actions.

01/2000-9/2006 Workers Compensation Claims Adjuster Crawford & Company Ȃ Melville, NY

Managed a portfolio of Workers Compensation claims for Northeast Jurisdiction NY, CT and PA. Ensuring prompt and accurate resolution.

Conducted thorough investigations into claim validity, including reviewing medical records witness statements and accident reports.

Collaborated with medical Management team due to complexity of injury and potential long-term disability or permanency to discuss large settlement to ensure compliance with New York State Workers Compensation laws and regulations.

Extensive reporting quarterly on opened claims with carrier to discuss claim resolution and indemnity/medical exposure.

Worked closely with SIU department to determine fraudulent claim. EDUCATION

CAPELLA UNIVERSITY, MINNEAPOLIS, MN

PRESENT

BACHELOR OF SCIENCE BUSINESS SPECIALIZATION HEATHCARE MANAGEMENT EXPECTED GRADUATION DEC 2024

CERTIFICATION

WCP DESIGNATION

LICENSED NOTARY PUBLC

SIX SIGMA GREEN BELT

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