WC Adjuster

SHAWI (Shay) WASHINGTON

Letohatchee, AL ***** 334-***-**** ****************@*****.***

PROFESSIONAL SUMMARY

Management in claim resolution, negotiation, and appeals, coupled with exceptional attention to detail and effective communication. Recently obtained Workers' Compensation Adjuster license for the state of Alabama and Texas, eager to leverage skills in a new role within the workers' compensation field.

SKILLS

Workers' Compensation Claims Investigation

Claims Adjudication

Reserve Calculation

Litigation

Subrogation

Medical Billing & Terminology

Appeals and Denial Management

Effective Communication

Analytical Skills

WORK HISTORY

Account Claims Associate – Workers Compensation, 11/2024 - Current

Absolute Staffing and Consulting Solutions – Westminster, MD

Reviews and evaluates insurance claims for accuracy, compensability, and completeness.

Investigates and manages insurance claims to determine the extent of the insurer’s liability.

Interacts with claimants, medical professionals, and insurance providers to gather necessary information.

Interprets policy coverage and determines if the claim was covered.

Calculates and validates reserves based on the terms of the policy.

Documents all steps in the claim process, from initial evaluation to final settlement.

Worker Compensation and MVA Claims Analyst, 07/2023 – 08/2024

QMACS, INC – Richardson, TX

Contacted patients, carriers, and adjusters to obtain necessary claim information for medical bill submissions.

Researched workers' compensation claims for reconsiderations or formal appeals, successfully overturning 75% of initial denials.

Negotiated settlements for MVA and Workers' Compensation claims, achieving an average reduction of 15% in settlement times.

Disputed denials and examined claims for underpayments based on current fee schedules, recovering over $50,000 in underpaid claims.

Adjudicated claims, ensuring compliance with company policies and regulatory standards, maintaining a 95% accuracy rate in account closures.

Claims Research Associate, 03/2023 - 07/2023

Apex Systems – Birmingham, AL

Resubmitted workers' compensation claims for adjudication, reducing the average claim resolution time by 25%.

Conducted comprehensive reviews of denied workers' compensation claims, resulting in a 40% increase in successful appeals.

Verified required documents to ensure resolution and customer satisfaction, achieving a 90% customer satisfaction rate.

Adjudicated claims according to guidelines, maintaining compliance with all regulatory requirements and company policies.

Workers' Compensation Analyst, 05/2021 - 03/2023

Aspirion Health Resources – Columbus, GA

Verified and obtained claim status via telephone, web portals, or fax, improving follow-up efficiency by 20%.

Conducted thorough analysis of aged workers' compensation claims, recovering over $100,000 in overdue payments.

Maintained detailed records and updated weekly spreadsheets tracking account status, reducing errors by 15%.

Researched accounts to determine if EMR was needed for claim resolution, leading to a 10% increase in claim resolution speed.

Adjudicated claims to ensure compliance with regulatory standards, increasing the accuracy and efficiency of claims processing.

Reviewed questionable claims with claimants and employers to correct omissions and errors.

Medical Secretary, 04/2020 - 10/2020

Medical Care NA – Montgomery, AL

Managed front desk operations efficiently, greeting patients warmly and addressing their concerns professionally.

Answered telephone calls to provide office information, answer questions, and direct calls to staff.

Maintained a clean and organized office environment to promote a positive atmosphere.

Assisted with administrative functions related to patient care, streamlining office operations and reducing waiting times.

Scheduled patient appointments, improving scheduling efficiency.

Obtained medical records for accurate assessments, ensuring 100% compliance with patient privacy regulations.

Registered new patients and explained treatment forms, enhancing the onboarding experience and satisfaction.

Personal Aide, 04/2014 - 11/2019

LPHCS – Montgomery, AL

Coordinated daily and weekly schedules for elderly clients and aides, improving care consistency and client satisfaction.

Assisted with bathing, exercise, and meal preparation, contributing to improved client health and well-being.

Transported clients to and from medical appointments, ensuring timely arrival.

Documented daily vital signs and medical concerns, providing critical information to primary physicians.

Assisted with payroll and time sheets, ensuring accurate and timely payment.

Expanded clientele by 15% through assessing new cases of client care.

EDUCATION

Associate of Applied Science: Healthcare Management

Expected in 2025 The College of Health Care Professions - Houston, TX

GPA: 4.0

CERTIFICATIONS

Licensed WC Adjuster for State of AL: License# 300-***-****

Licensed WC Adjuster for State of Texas: License# 3270110

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