Service Rep Workers Compensation

Magaly Diaz

Irving, TX ***** 972-***-**** ******.****@*****.***

Experience

Liberty Mutual Insurance

June 2021-Current

Senior WC adjuster

Licensed in TX, OK, GA, FL, NC, & SC, CO

Manage inventory of claims to evaluate WC compensability, and establish plan based on case facts. Negotiate claims to settlement in appropriate jurisdictions and leverage medical resources to review and manage medical treatment for injured workers. Perform senior duties as assigned.

Texas Mutual Insurance Company October 2012- June 2021

Licensed Workers Compensation Adjuster

Analyze and manage moderate to complex claims by investigating and gathering information to determine the compensability on the claim. Manage claims through well-developed action plans to an appropriate and timely resolution. Calculate and pay benefits due, approves and makes timely claim payments and adjustments; and ensure claim files are properly documented and claims coding is correct.

Zurich Insurance North America February 15th 2012-October 2012

Licensed Workers Compensation Adjuster

Manages moderate worker’s compensation claims with lost time. Licensed to adjust in Louisiana, Texas and Oklahoma. Analyze and investigate claims to determine compensability, monitor reserves on each file and set appropriately. Calculate payments and negotiate settlements of claims within designated authority, coordinates vendors referrals for additional investigations and or litigations. Uses appropriate cost containment techniques including strategic vendor partnership to reduce overall cost for our client.

Sedgwick CMS

December 2008- January 2011 Disability Specialist I

Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to a disability plan based on medical information that is received. Determination is based on thorough review and knowledge of observable medical information that is obtained with the knowledge of ICD-9 codes and CPT codes. Determines benefits due along with investigating any other types of offsets necessary, such as Workers compensation, state disability etc. Communicates clearly with claimant and client on all aspects of claims process either by phone and/or written correspondence. Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims. Maintains a quality assurance program to support the total performance management initiative and the consistent delivery of quality claims service

Sedgwick CMS

October 2006 – December 2008 Customer Service Rep II/ Team Lead

Acts as primary liaison with customer in solving problems related to the application process of short term disability claim and Workers Compensation claims and service. Educates and informs the customer by telephone, written correspondence and/or the claims system about the documentation required to process a claim, required time frames, payment information and claim status. Enters verbal and written application information that meets both the internal and external customer's requirements accurately into the claims management system. Assigns new claims to the appropriate claims handler. Directs customer calls to the correct person at all locations. Provides training for employees, assistants with escalated calls and maintains team performance a quality service culture within the Customer Service Team. Supports the Total Performance Management initiative.

Education:

University of Dallas Irving, TX

Political Science Major

73 credit hours completed.

Languages:

English and Spanish

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