Senior Workers Compensation Claims Examiner

Peggy D. Harper

702-***-**** ***************@*******.***

Professional Licensing/Designations

University of Nevada, Las Vegas-Masters of Public Administration 1996

State of Nevada Hearings Division Workers Compensation/Hearings License 2000

Insurance Institute of America-Associate in Claims(AIC) 2002

Registered Workers Compensation Specialist (RWCS) 2007

Insurance Institute of America-Associates in Risk Management (ARM) 2009

The Institutes-Associates in General Insurance (AINS) 2012

The Institutes-Chartered Property Casualty Underwriter (CPCU) 2013

California Self Insured Program (SIP) 2016

State of Nevada Adjuster License 2018

Arizona Insurance License 2019

State of Idaho Adjuster License 2020

Professional Experience

January 2021-

Senior Claims Specialist

Conduct investigations with employers, injured employees, and medical staff consisting primarily of COVID claims or other complex claims for municipalities within the State of California for compensability. Identifies opportunities for subrogation and subsequent injury activities. Calculates wages and reimburses the employer per salary continuance guidelines. Established appropriate reserves and monitored reserve adequacy.

March 2020 – January 6th, 2021, Brentwood Service Administrators

Senior Workers' Compensation Claims Specialist

Participates in file reviews with clients and identified cost saving measures to reduce overall costs of claims. Identifies and initiate mitigation, subrogation and other recovery opportunities on assigned claims. Conducts investigations and reviews complex claims for compensability. Monitors claims and updates action plans to ensure timely resolution of any legal/medical issues. Establishes appropriate reserves and monitors reserve adequacy throughout the life of the claim. Negotiated claim settlements, including inputting and approving payments within delegated authority.

September 2019 – March 2020, Broadspire Claims Services

Senior Workers' Compensation Claims Examiner

Investigates claims for compensability and issues acceptance/denial determinations. Reviews claim for appropriate referral to defense attorneys and offers recommendation to client/defense attorneys to appeal to the next level. Calculates Temporary Total Disability and Permanent Disability ratings to ensure timely payment of benefits. Establishes the initial reserves and updates reserves based on best practices. Schedules appointments and refers injured employees to appropriate specialists to facilitate medical treatment and resolve barriers for early return to work. Identifies claims for potential subrogation and subsequent injury referrals.

October 2018 – August 2019, Athens Administrators

Senior Workers' Compensation Claims Examiner

Provided Third Party Administrator services for California clients/claims. Issued claim determinations to accept, deny, or delay claims. Managed the litigation process by assigning defense attorneys and identifying potential litigated issues early in the claim process. Ensured that Medicare Set Asides are addressed prior to claim closure. Calculated Temporary Total Disability and Permanent Disability ratings. Established appropriate reserves to account for anticipated costs throughout the life of the claim based on best practices. Negotiated liens with lien claimants and EDD to reduce settlement costs under the claim. Scheduled appointments and referred applicants to appropriate PQME and AME providers to obtain expert opinions, treatment recommendations, and facilitate medical treatment.

March 2018 – September 2018, Corvel Corporation

Senior Workers' Compensation Claims Examiner

Analyzed and processed complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution. Negotiated settlement of claims within designated authority. Calculated and assigned timely and appropriate reserves to claims; managed reserve adequacy throughout the life of the claim. Calculated and paid benefits due; approved and issued timely claim payments and adjustments; and settled clams within designated authority level. Managed the litigation process; ensured timely and cost effective claims resolution. Represented the employer before the Hearings Officer.

September 2017 – February 2018, Gallagher Bassett Services

Senior Workers' Compensation Resolution Manager

Accomplished 24-hour contacts with all parties involved in the claim process. Maintained contact with the client, injured employee, attorney representative and medical providers throughout the life of the claim. Developed and communicated action plans to the client which include recommendations to move the claim to appropriate resolution/closure. Processed claims consistent with clients’ and corporate policies, procedures and “best practices” and also in accordance with statutory and regulatory requirements. Complied with carrier reporting and threshold requirements. Identified claims which met excess reporting requirements and pursued excess insurance recoveries.

June 2001 – August 2017, Sedgwick Claims Management Services

Senior Workers' Compensation Claims Examiner

Responsible for administering claims for the St. Rose Dominican Hospitals and St. Mary’s Health Network. Complied with state workers compensation statutes/codes, and Division of Industrial Insurance directives. Participated in file reviews with clients and identified cost saving measures to reduce overall costs of claims. Identified and initiated mitigation, subrogation and other recovery opportunities on assigned claims. Complied with state audit requirements. Maintained data not captured in the claims management system and coordinated with the data analyst for audit preparation or required state filing within statutory limits. Conducted investigations and reviewed complex claims for compensability. Managed subrogation and subsequent injury activities. Monitored claims and updated action plans to ensure timely resolution of any legal/medical issues. Established appropriate reserves and monitored reserve adequacy throughout the life of the claim. Negotiated claim settlements, including inputting and approving payments within delegated authority. Communicated the medical and indemnity benefits for injured workers and promptly addressed questions/concerns.

JULY 1992-MAY 2001, TEAM LEAD/SUPERVISOR STATE OF NEVADA

Responsible for managing workers’ compensation team consisting of indemnity claims examiners, nurse, vocational rehabilitation counselor, claims representatives, bill payers, and administrative support personnel.

Attended file reviews with clients and developed action plans to resolve treatment or legal issues.

Planned, organized, established priorities, determined realistic completion dates, and communicated the status of claims. Investigated and administered complex claims and issued determinations based on extensive experience and knowledge of regulations and administrative code.

Represented the employer before the State of Nevada Hearings Officer.

Pursued claim recovers through subrogation and the Subsequent Injury Fund.

Coordinated with the legal department and negotiated claims settlements within authority level.

Contact this candidate