Claims Adjuster/Workers' Compensation

Published on May 2016 | Categories: Documents | Downloads: 24 | Comments: 0 | Views: 256
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Claims Adjuster/Workers' Compensation with 35 years experience looking for a Direct Contributor position.



Mary Lou McLaughlan 8398 Elizabeth Lake Road * White Lake, Michigan 48386 * 248.698.4545 * 248.842.4621 * [email protected] WORKERS' COMPENSATION CLAIMS SPECIALIST "Success is not a matter of desire, but the product of hard work." Hands-on, motivational contributor with years of progressively challenging exper ience achieving or exceeding desired business outcomes. Exceptional ability to c learly translate complex issues into actionable plans aligned to short and longterm requirements. Establish quick rapport with co-workers, professionals and st aff. Exercise diplomacy and tact; enjoy a reputation of relational excellence, a nd overcoming obstacles critical to performance metrics. Uphold highest standard s for ethics and quality. Effectively evaluate and proactively manage performanc e against relevant benchmarks. Thrive under pressure. Build and maintain excepti onal, productive relationships with clients and colleagues. CAREER TRACK TRAVELERS INSURANCE Troy, Michigan INVESTIGATIVE CASE MANAGER Since 2005 Responsible for aggressively investigating and handling lost time claims, with s trong focus on customer satisfaction for large national accounts, including but not limited to Masco Corporation, Coco-Cola, Herman Miller, Rite Aid Drug Stores , and Lear Corporation. Work in close concert with clients, physicians, and clai mants to gather information, confirm eligibility, and to make a timely determina tion on compensability, coverage, and off set issues. Refer non-controverted cla ims to appropriate Case Managers, and retain and manage controverted claims to f inal conclusion. Assignments also include self-insured, mid-sized markets, and a ssigned risk pool. * Plan and conduct a thorough investigation on questionable claims. Liaise and c ommunicate closely with medical professionals, insured, and injured employees to gather information and make informed decisions. * Develop litigation strategies as required in concert with Hearing Representati ves and Defense Council of Travelers and the clients, and to maximize client abi lity to pay or deny claims. On retained cases, estimate projected exposure to as sist management in making sound decisions. * Provide on-site claims training geared to assist Coca-Cola supervisors in the importance of timely filing of workers' comp claims. Program spans 2.5 days to e nsure all relevant personnel complete the program. * Consistently delivered high-volume requirements at world-class level of qualit y. Prepared for emerging client needs to guarantee satisfaction and facilitate l ong-term business relationships. In addition, reduced inventory, and went above and beyond to exceed management and client expectations. WORKERS' COMPENSATION CLAIM PROFESSIONAL 1984 - 2005 Managed all accepted lost time claims, including CAT claims. Primary duties cons isted of performing telephonic case management of Workers' Compensation claims. Contacted injured worker, employer, and medical provides in a timely manner to g ather relevant information to assist in the investigation and evaluation of the claim. Managed to conclusion all lost time claims. * Managed files, with an emphasis on file quality (including timely contact and proper documentation), maximizing internal resources, and achieved a positive en d result by returning injured party to work. * Aggressively pursued claim resolution opportunities. Build strong partnership with internal nurse resource (Medical Case Manager) in order to integrate the de livery of medical services to the injured worker. * Identified claim issues as they arose, and took appropriate steps to resolve t hem or referred them to the Unit Manager for reassignment. Established appropria te reserves to reflect claim exposure. Continued Mary Lou McLaughlan Page 2 * Workers' Compensation claim handling experience included investigation skill, resolution skills, evaluation, negotiation, and reserving skills. Utilized compl ete understanding of all policy, coverage, endorsement implications, AOE/COE iss

ues, technical and jurisdictional and case law knowledge. Other skills included file management, technical, Customer Focus / Communication, Relationship Managem ent, and Technology. MEDICARE PROCESSOR 1974 - 1984 Worked in the Medicare Department. Reviewed skilled nursing homes and hospital b illings for payment. * Upon closure of department, transferred to the Workers' Compensation Departmen t. PROFESSIONAL TRAINING Numerous company-sponsored training sessions and workshops, including: MSA, Medi cal Terminology, Litigation, Coverage, Reserve, Negotiating Settlements, Recorde d Statements, and Customer Service. Seminars include: Workers' Compensation in the State of Michigan, The Right Cour se in Negotiations, Time Management, Power Communication Skills for Women REFERENCES AND FURTHER DATA PROVIDED UPON ESTABLISHMENT OF MUTUAL INTEREST

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