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available overnight available weekdays available weekends education completed: bachelors
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Licensed Claims Adjuster seeking work in the insurance field. My experience is below, it is primarily property, catastrophe, investigations, social work and workers compensation. I am open to other fields besides sales.
06/2017-09/2018 North American Risk Services Dallas, TX
Senior Claims Adjuster
• Investigated appropriate parties on worker compensation incidents to determine liability, benefits, compensation, negligence, compensability, and subrogation potential, as appropriate.
• Referred all files identified with subrogation potential to the subrogation department. Sent approvals/denials of claims to the states when investigation completed.
• Verified facts of loss and pertinent claims facts such as employment, wages, or damages and establish disability with treating physicians as appropriate.
• Identified cases for settlement. Evaluated claims and requested authority no later than 30 days prior to mediation date and negotiate settlement.
• Recognized and reported potential fraud cases. Recommended referral to SIU where appropriate and assisted the SIU in their investigation and settling of the claim
• Developed and directed litigation plans with defense attorneys, utilized all defenses and tools to bring the file to closure. Ensured all filings and state mandated forms were completed timely.
• Attended mediations and trials as required for cost effective litigation management.
• Paid all indemnity benefits, ensuring they are paid timely on state statute.
• Verified all provider bills have been appropriately reviewed and paid within standard timeframes.
• Reported all serious injuries/liability issues and potential large loss claims to the client and/or reinsurer based upon the criteria provided by the client. Prepared all large loss reports and sends to client for approval.
• Investigated workers compensation non-subscriber services for compensability, liability subrogation/third party recovery, coverage, approvals/denials.
• Coordinated with defense counsel, police, on litigated claims providing records, reports, and preparing for court as needed.
• Participated and arbitrations and mediations on complex cases.
• Issued indemnity benefits for injured workers exceeding state waiting periods.
• Communicated claim 3-point contact within 24 hours with recorded statements. Identifies all injuries with ICD-10 coding, knowledge of CPT codes.
• Identified suspicious claims. Recommended referrals to SIU when appropriate and assisted with field surveillance in the investigation, and settling of the claim.
• Lead several presentations on improving services within the company with customer service, litigation, payments, reviews, accuracy, repetitive claims, etc.
• Processed routine payments for prescriptions, medical equipment, mileage, and Medical Bills.
• Negotiated settlement of claims within designated authority, and manages all reserves using financial independent judgment.
• Authorized variety of medical services for the injured workers (MRI, Physical Therapy, DME, Orthopedics, Dental, EKG, CT scan, surgery, etc)
8/2013-4/2014 ADAPT of Texas McKinney, TX
• Trained/Supervised clients in jails, groups, and individual settings, on coping with disabilities, socialization, crisis, non-compliance, daily living, money, safety, etc.
• Conducted service plans for clients including budgeting, financial planning, and safety.
• Made referrals for vocational, Chemical dependency, Housing, employment, clothing, food, and other services.
• Taught mental health coping techniques from sate approved curriculum.
• Reassessed service plans every 90 days to measure goals, and progress, and modified it based on client progress.
• Responded to crisis situations with proper authority to meet client needs.
• Attended/conducted various trainings on Curriculums, Drugs, SSI benefits, HIV/AIDS, client rights, new medications, etc.
2/2010-3/2013 Tarrant County MHMR Fort Worth, TX
• Provided on-going 24-7 mental health services. Trained/Supervised clients in jails, group, individual, and classroom setting on coping with disabilities, socialization, daily living, employment, money, etc.
• Supervised services/intakes for the purpose of empowering clients to achieve goals set forth in the Treatment plan.
• Referred individuals to proper personnel regarding Substance Abuse, housing, employment, food, clothing and various other needs.
• Created training materials as needed, or taught them from curriculum.
• Supervised weekly doctor visits, cases, monthly budgets, check signing, medication, and crisis/conflict situations.
• Performed everyday customer service task with clients and vendors. Served as head liaison between the clients and outside agencies (DADS, TANF, DARS, legal system, Social Security, etc) regarding other services.
10/2005-12/2008 Federal Emergency Management Agency Texas/Louisiana
• Inspected property/casualty, auto, catastrophe, homeowner, Commercial, and Physical damages for The Hurricane Katrina Victims.
• Identified fraudulent claims, underwriting risks, within the guidelines and regulations.
• Prepared accurate estimates by utilizing estimation tools, systems, and contractor bids.
• Determined required and available resources for the recovery mission.
• Facilitated after-action reviews and disaster information with several agencies into recommendations to address areas for improvements.
• Expedited all government assistance applications with emergency notifications to various agencies (DHS, Medicaid, Medicare, SSI, Housing Authorities, GPA, etc)
• Negotiated with claimants to diffuse issues regarding losses/coverage, escalated all claims as advised by the government.
June 2005 Ouachita Baptist University Arkadelphia, AR
• Bachelor of Arts Degree in Psychology with a minor in Sociology
All lines claims adjuster license (multi states), Microsoft Word, access, Suite, Excel SharePoint, Visio, PowerPoint, QuickBooks, Kronos, ICD-9, ICD-10, Needles, Xactimate, CCC Pathways, Accupro.
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do NOT contact me with unsolicited services or offers