Workers Compensation North Carolina
Resume:
Susan Diane Thomas
Raleigh, NC 57603
************@*****.***
Objective: I am a highly self-motivated, loyal individual with positive attributes and valuable expertise experience in workers’ compensation on East Coast states, with the ability to succeed within any professional environment. I work well in a team setting while I am also able to work efficiently on my own.
Education: Graduate, J F Webb High School, 1987; Vance Granville Community College: Safety Education, Human Growth and Development, Composition, Access, Keyboarding, Word. Licensure and Experience: South Carolina Adjuster/Insurance License/Lines of Authority
(Casualty, Commercial Lines, Marine, Personal Lines, Surety, Workers Compensation); Non- Resident adjuster License North Carolina 25 years specialty of this state and 2-4 Georgia, South Carolina and 13 years in Tennessee; Experience of back up for all other States of Florida, Arkansas, Alabama, Mississippi, and Kentucky: Virginia; Tennessee Certified Adjuster Designation: Certified Builder’s Insurance Agent; Certified Workers Compensation Professional.
Computer Courses: Microsoft office, Windows, Word/Excel, Access (data Base), Keyboarding, AS 400, lotus Notes, Quick Books, Power point, Excel, Power Point, Foxit; Microsoft Teams, Outlook, CMS, dfFiller integrations and IVOS/Mitchel Electronically filing Systems. Experience:
Brentwood Claims Services:
December 2, 2024-March 3, 2025
Senior Claims Examiner
Effectively investigate and manage large accounts (City of Gastonia, Grady Health Systems, Henry County Schools), caseload of approximately 125-150 various Large Complex Indemnity and Catastrophic North Carolina, Georgia, back up for all other states on East Coast workers compensation claims, backing up all other states on the East Coast
Review documents/mail, analysis, three-point contacts, recorded statements, and investigation of the information, to determine the compensability for the loss, based on state law and in accordance with established Company guidelines and a timely manner.
Evaluate subrogation/pursuing any recovery potential, setting appropriate reserves based on client’s formats, authorize, and process payments within the authority.
Maintaining detailed hearings, Mediations, and hearing logs; collaborating closely with the legal counsel, supervising litigation, investigating large lost claims/CAT medical case management for adherence and outside vendors for cost containment.
Maintaining 30/60/90 days diaries reports, excess carriers’ reports, participate in claims reviews with the clients to resolve the matters and settlements within the authority up to 250,000 pursuant to guidelines and maintaining a professional customer relationship. Sedgwick Claims Management:
November 2021 to 11/30/24
Senior Claims Examiner
Effectively investigate and manage large accounts (American Airlines/PepsiCo), caseload of approximately 125-135 various Large Complex Indemnity and Catastrophic North Carolina, South Carolina and Georgia, back up for all other states on East Coast workers compensation claims, backing up all other states on the East Coast Review documents/mail, analyzing, three-point contacts, recorded statements, and investigation of the information, to determine the compensability for the lost, based on state law and in accordance with established Company guidelines and a timely manner.
Evaluate subrogation/pursuing any recovery potential, setting appropriate reserves based on client’s formats, authorize, and process payments within the authority.
Maintaining detailed hearings, Mediations, and hearing logs; working closely with the legal counsel, supervising litigation, investigators and CAT medical case management for adherence and outside vendors for cost containment.
Maintaining 30/60/90 days diaries reports, excess carriers’ reports, participate in claims reviews with the clients to resolve the matters within settlements, obtaining authority approval pursuant to guidelines and maintaining a professional customer relationship. Tristar Risk Management:
February 2021 to November 2021
Claim Examiner III/Senior Adjuster
Effectively investigate and manage with minimal supervision a caseload of approximately 125-150 various modest to Large Complex Indemnity/CAT North Carolina, South Carolina, Georgia, Mississippi, and back up for other states listed above workers compensation claims with exposure of $75,000.00 or greater.
Review documents/mail, analyzing, three-point contacts, recorded statements, and claim investigation of the information, to determine the compensability for loss, based on state law and in accordance with established Company guidelines and a timely manner.
Evaluate subrogation/pursuing any recovery potential, setting appropriate reserves based on client’s formats, authorizing loss and expense payments within authority.
Maintaining detailed suit, arbitration/Mediations, and hearing logs; assignment of legal counsel, investigators and medical case management for adherence and supervising litigation activities and outside vendors.
Maintaining 45-60 days diaries reports, excess carriers report, participating in claims reviews with the clients and resolving matters within settlements, obtaining authority approval pursuant to guidelines and maintaining a professional customer relationship. Professional Rehabilitative Options, Inc.
January 2020-Feburary 2021
Business Development Manager
• Responsible for generating new business and achieving market research.Goals and objectives developing guidelines and business referrals for MRI, CT scans, and DME cost effectiveness. In alignment with corporate long-term strategic goals. Seeking out new business opportunities and negotiating and secure contracts for products and services within assigned authority parameters.
• Responsible for continuous monitoring of the PRO service market demands, trends, and changing conditions for the Developed the procedures, guidelines and all the protocols for newly developed company/business PRO Medical Solutions, LLC. from the point of the initial sale, scheduling, ordering, invoicing protocols for accounts receivable and accounts payable. North Carolina League of Municipalities:
November 2017-October 2019
Senior Claims Adjuster/Workers Compensation
Managed complex lost time/CAT and Medical only workers compensation claims for local government, recorded statements, performing interviews, reviewing medical records, accepting, or denying claims, adjusted reserves for exposure, and assigned outside vendors for cost effectiveness of the exposure. Claims Audits and reviewing complex claims.
Payments for all Temporary Total, Permanent Partial benefits, and settlement checks as they were due to injured workers, by calculating and paying compensation.
Negotiate Settlements, attend mediations, hearings, and deposition, as necessary.
Resolution of the claim with cost effectiveness on complex claims, and within the requirements of Medicare Set Aside, with settlement authority of $250,000.
Wrote all corresponding legal letters and responses to legal counsel.
Filed all Formal Forms with North Carolina Industrial Commission.
Overseeing scheduling education and training for CE classes. Builders Mutual Insurance Company /Aegis Administrative Services: November 2011- November 2017
Senior Claims Adjuster/Workers Compensation
Managed all Complex lost time/CAT workers compensation files for the State of North Carolina, South Carolina and Tennessee workers compensation claims, and back up for other states licensed in recorded statements, performing interviews, reviewing medical records, accepting or denying claims, adjusted reserves for exposure, and assigned outside vendors for cost effectiveness of the exposure, as well Multiple states: NC, SC, VA, Maryland, Florida as extended coverage for company.
Payments for all Temporary Total, Permanent Partial benefits, and settlement checks as they were due to injured workers, by calculating and paying compensation.
Negotiate Settlements, attend mediations, hearings, and deposition, as necessary.
Resolution of the claim with cost effectiveness on complex claims, and within the requirements of Medicare Set Aside.
Wrote all corresponding legal letters and responses to legal counsel.
Filed all formal Forms with North Carolina Industrial Commission and with Tennessee Department of Labor and Workforce.
Corvel
June-2009-November 2011
Senior Claims Adjuster/Workers Compensation
Managed all Complex lost time/CAT workers compensation files for the Department of Corrections workers compensation claims in North Carolina, recorded statements, performing interviews, reviewing medical records, accepting, or denying claims, adjusted reserves for exposure, and assigned outside vendors for cost effectiveness of the exposure.
Payments for all Temporary Total, Permanent Partial benefits, and settlement checks as they were due to injured workers, by calculating and paying compensation.
Negotiate Settlements, attend mediations, hearings, and deposition, as necessary.
Resolution of the claim with cost effectiveness on complex claims, and within the requirements of Medicare Set Aside.
Wrote all corresponding legal letters and responses to legal counsel.
Filed all Formal Forms with North Carolina Industrial Commission and with Tennessee Department of Labor and Workforce.
Corresponded with Attorney General with all matters of the State claims and advised of settlement recommendations for state budgets.
KeyRisk Management Services Company
April 2007-June 2009
Senior Claims Adjuster/Workers Compensation
Managed all Complex lost time/CAT workers compensation files for the Department of Corrections workers compensation claims in North Carolina, recorded statements, performing interviews, reviewing medical records, accepting, or denying claims, adjusted reserves for exposure, and assigned outside vendors for cost effectiveness of the exposure.
Payments for all Temporary Total, Permanent Partial benefits, and settlement checks as they were due to injured workers, by calculating and paying compensation.
Negotiate Settlements, attend mediations, hearings, and deposition, as necessary.
Resolution of the claim with cost effectiveness on complex claims, and within the requirements of Medicare Set Aside.
Wrote all corresponding legal letters and responses to legal counsel.
Filed all Formal Forms with North Carolina Industrial Commission and with Tennessee Department of Labor and Workforce.
Corresponded with Attorney General with all matters of the State claims and advised of settlement recommendations for state budgets settling within the authority given by State. Aegis Administrative Services/Builders Mutual Insurance Company: May 2001 April 2007
Workers Compensation Adjuster
• Adjusted claims, All lost time and Medical only workers compensation files for the State of North Carolina and Tennessee within the assigned territory.
• Managed all processing duties with both medical and lost time files within the assigned claims.
• Settled files, attend mediations, hearing and deposition claims handling, as necessary.
• Resolution of the cost effectiveness of the caseloads within my area. Senior Processor/Medical only Adjustor:
• Assisted with North Carolina and the state of Tennessee lost time claims for the supervisor.
• Processed payments on all medical bill(s), Processed Temporary Total Benefits, Permanent partial benefits, settlement checks and reimbursements to the injured worker for travel and prescriptions as needed.
• Review and monitor all injured workers medical record(s) and claim status.
• Wrote all corresponding letters to plaintiff attorney as needed.
• Filed all legal Formal Forms with North Carolina Industrial Commission and with Tennessee Department of Labor and Workforce.
Pronto Automation Technology, Inc:
October 1999-May 2001
Executive Administrative Assistant
• Assisted the president in any secretarial/Receptionist duties for the executive/present of company.
• Set up all credit accounts. Manufacture certificates, billing, and leasing contracts.
• Human Resources: insurance claims, Workers Compensation filings, record keeping, maintained personnel records, attendance records, timecard(s) and payroll records.
• Accounts Payable: Invoicing, all incoming bills petty cash.
• Shipping/receiving Department: received all incoming merchandise and outgoing merchandise into the system.
• Clerical duties: typed all company legal documents, filing and records, including work orders, and closure of files.
• Purchasing Department duties, managing all purchasing for the company needs, input purchase orders.
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