Claims Examiner Senior
Resume:
David Diaz
Concord, CA 94520
***********@*****.***
Education:
James Monroe University
Bachelor of Arts in Business Administration and International Relations Certifications / Licenses:
Workers Compensation Claims Professional, WCCP
Self-Insurance Plans Certified, CA
Associate of Risk Management (enrolled)
*Bilingual – Spanish & Portuguese
Experienced Senior Claims Examiner and Lien Negotiator with a demonstrated history of working in the insurance industry with a specialty in defense litigation of liens and cost-petitions. Strong claims professional with a Bachelor of Arts (B.A.) focused on Economics and risk management. Competent all things liens, costs & interpreters copy Service subpoena non-IBR and settlement walk-through expert. Professional Summary
Workers’ Compensation Claims Professional with demonstrated skills in litigation management, complex claims handling involving MSA reductions, life pension, permanent total disability, death, COVID-19, idiopathic stroke, and asbestos exposures. Extensive claims handling experience with large-dollar reserves involving present proposed reserve increase to senior leadership. Strong presentation skills, having developed extensive original reference and training materials including color flowchart for post-termination defense, copy service Non-IBR process and Labor Code 5811 costs. Technically strong combined with demonstrated leadership abilities and excellent interpersonal skills necessary to develop, nurture, and maintain positive relationships with individuals at all levels of an organization, including internal customers and outside business partners. In-depth knowledge of California Workers’ Compensation Laws, including experience modification calculation. Talented at conceiving and development of strategic initiative plans to create new processes. Skilled in evaluation and interpretation of medical reports, understanding of legal concepts, AMA impairment rating, and affirmative defenses. Possess a high level of flexibility and ability to build excellent rapports with internal staff and outside partners in successfully getting cases closed. Professional Experience
AmTrust Financial Services, Concord, CA
(August 2022 to March 2023)
Senior Claims Examiner / Lien Negotiator
• Responsible for managing an assigned lien and complex case-in-chief case load of 150 files. Developed a cost-effective lien settlement plans coordinating with bill review to effectively settle hundreds of liens. Reviewed lien files set for lien conferences and trials to ensure the stipulations and issues were prepared.
• Provided advice to senior AmTrust leadership on processes and defenses regarding LC 5811 cost petitions, non-IBR petitions and liens from suspended providers.
• Appeared at lien conferences, successfully representing AmTrust and drafted a hearing summary delineating exposure and defenses.
• Assisted claims examiners and less-experienced lien negotiators in evaluating provider services with an emphasis on threshold issues, duplication, over utilization and identified valid defenses using applicable statutes and caselaw.
AmTrust Financial Services
(Jan 2018 to August 2022)
Senior Claims Examiner / Team Lead
• Handled catastrophic losses involving traumatic head injuries, spinal cord injuries, and multiple trauma injuries, including 100% cases under Ogilvie, Dahl and Leboeuf.
• Act as back up for the unit manager in his absence— provide mentoring and leadership to the claims department.
• Spearheading with upper management first-ever copy service billing mitigation process.
• Completed first-ever comprehensive copy service flowcharts for non-IBR medical-legal dispute and second bill review/IBR processes.
• Completed first-ever AmTrust proper petition for determination of a non-IBR medical-legal dispute.
• Responsible for drafting Compromise & Release agreements and Stipulations with Request for Award in pro per and represented cases for walk-throughs. Expertly drafted MSA addenda to ensure Medicare’s interest were taken into consideration.
• Assigned to investigate new losses by conducting recorded statements, determining compensability on complex claims such as general-special employment and post-termination situation.
• Completed first draft objection notice non-IBR medical-legal dispute.
• Assisted management in preparing open pending of 1500 files for state audits.
• Training new unit Claims Adjusters, which included producing a comprehensive Quick Reference WC handbook for professional development.
• Handled all aspects of defense litigation to include filing Answers, Petitions for Dismissal, objections to QME specialty designations, and completing settlement documents, resulting in tens of thousands of legal cost savings to insureds.
Risico Risk Management, Fresno, CA
(July 2017 to February 2018)
Senior Claims Examiner
• Responsible for review of all indemnity claims every 30 to 45 days to ensure file progression over a caseload of 150 + files involving dedicated County of Fresno and City of Fresno Police accounts under the statutory and ADR carve-out.
• Review medical reports for in relation to initiating, stopping, or denying benefits. Process a large volume of incoming mail in relationship with medical necessity requests for treatment and IMR requests or determinations. Review every 60 days all files for reserve adequacy throughout the life of the claim. Develop and manage claims through well-developed action plans. Prepare necessary state filings within statutory limits. Actively manage the litigation process. Determine benefits due under statutory and LC 4850; make timely claim payments and adjustments.
Keenan & Associates; San Jose, CA
(December 2013 to July 2017)
Senior Examiner, School District Accounts
• Dedicated W/C senior examiner for Alisal USD and Orange USD, responsible for investigating and administering a caseload of 150 indemnity files towards resolution and closure under the Labor Code, Education Code, and Government Code sections relative to workers' compensation of public entity school districts.
• Responsible for setting appropriate reserves and keep excess carriers informed when losses potentially exceed the JPA self-insured retention levels.
AIMS; Santa Clarita, CA
(September 2010 – December 2013)
Claims Examiner
• Worked on the County of Los Angeles Account handling public safety officers’ indemnity claims. Administered a caseload of 135 claims for the County of Los Angeles.
• Performed examiner du-ties including but not limited to the investigation of new claims, resolution of technically complex files, ensured appropriate reserves were set, sought recovery through subrogation and or contribution from third parties, and participated in account monthly file review. Sedgwick CMS, Orange and Los Angeles, CA Long-term contract assignments
(July 2006 – September 2010) Claims Examiner
• Responsible for caseloads of 180-210 indemnity files for self-insured and high-premium clients
(Kmart/Sears Roebuck Co.; Boeing Aerospace; Kroger Grocery).
• Effectively managed Workers’ Compensation Claims from initial reporting to the conclusion. Monitored medical care and indemnity benefits, prepared for and attend claim reviews with clients, reviewed and evaluated claims for PD, medical exposures, and subrogation potential. Actively set up files and scheduled medical, medical-legal, and investigative appointments.
• Negotiated and settled claims with claimants, attorneys, and lien holders. Ensured the timely payments of claimants’ temporary, permanent and disability benefits.
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