Objective
To obtain a challenging position utilizing my case management, negotiation, analytical, computer, and bilingual skills.
Experience
EMPLOYMENT HISTORY
Interstate Personnel Services, Torrance, CA 2011-Present
Customer Service Representative
• Provide customer service to clients, providers and plan participants.
• Research claims status.
• Assist with eligibility issues.
• Reply to provider inquires.
• Review claims previously processed incorrectly to designated personnel with recommended corrective actions.
. Broad knowledge in medical claims processing, HIAA and medical terminology.
. Excellent telephone oral and written communication skills.
. Detail oriented with excellent organizational skills.
. Other duties as assigned.
The Doctors Company, Century City, CA 2008 – 2010
Claims Specialist
. Conduct investigations to gather evidence and facts sufficient to make appropriate decisions including
but not limited to obtaining review of medical records and expert opinions.
. Seek consultation on coverage issues; evaluates liability and damages; determine appropriate course
of action for case resolution. Make decisions and take action within authority.
. Obtain written consent from policyholders: negotiate settlements; utilize appropriate methods,
such as mediation, ADR and structured settlements.
. Communicate payment or denial to policyholders, claimants and others.
. Document files to support decisions.
. Maintain proper coding and reserves on assigned cases.
. Prepare required reports for all governmental agencies.
. Obtain all appropriate closing documents with include, but are not limited to: a full release, minor’s
compromise, satisfaction of liens, good faith settlement findings, satisfaction of judgement.
. Ability to do field work promptly and without assistance, such as on-site investigations, photography
interviews away from office, etc.
. Broad knowledge of medical legal issues.
. Excellent telephone, oral and written communication skills.
. Detail oriented with excellent organizational skills.
. Other duties as assigned.
Sedgwick CMS, Long Beach, CA 2003-2007
Senior Claims Examiner III
. Reviewed and analyzed general liability injury and property related claims submitted by client to determine reserves
. Interviewed client to determine facts and witnesses of claim
. Contacted claimant/attorney on allegations, medical status on specific injuries and obtained recorded statements from
Claimant’s and witnesses
. Evaluated claim to determine statue of limitations
. Prepared and developed action plan to complete investigation and evaluation
. Reviewed and analyzed demand package for settlement
. Negotiated for settlement purposes with claimant/attorney within reserves
. If claim is not resolved, prepared claim for lawsuit to be sent to defense counsel
. Set up a mutual action plan with defense counsel for resolution of the lawsuit
. Reviewed defense counsel’s budget to determine if within Sedgwick guidelines
. 30-90 day follow up with defense counsel to determine if litigation was within guidelines, if lawsuits were resolved
Re-evaluated litigation, prepared and revised mutual action plan and budgets.
. Attended small claims, mediations and mandatory settlement conferences
. Committed to the industry and flexible or adaptable to any proposed changes in the liability program, excellent
communication skills dealing with all levels of management, clerical, accounting and bill processing involved.
Ralph’s Grocery Company/Food 4 Less, Compton, CA 1990-2003
Senior Claims Examiner
. Reviewed and analyzed general liability injury and property related claims submitted by client to determine reserves
. Interviewed client to determine facts of claim
. Contacted claimant/attorney on allegations, medical status on specific injuries
. Evaluated claim to determine statue of limitations
. Reviewed and analyzed demand package for settlement
. Negotiated for settlement purposes with claimant/attorney within reserves
. Prepared unresolved claims for lawsuit and sent to defense counsel
. Set up a mutual action plan with defense counsel for resolution of the lawsuit
. Reviewed and analyzed defense counsel’s budget
. Attended small claims, mediations and mandatory settlement conferences
. Committed to the industry and flexible or adaptable to any proposed changes in the claims program, excellent
communication skills dealing with all levels of management, clerical, accounting and bill processing involved.
ABC Supermarkets, Inc., Los Angeles, CA 1986 - 1990
Human Resource Administrative Assistant
. Assistant to Human Resource Director
. Provided and kept a daily, weekly, monthly calendar of all Human Resource Directors activities.
. Set and scheduled all Human Resource Directors appointments.
. Interaction with all Agency’s with regards to filling temporary or permanent positions.
. Interviewed prospective clients and employees
. Performed clerical duties, accounting, 10 key by touch, interpreter
. Set up and inputted all new hire benefits, wages, including management, salaried, non-salaried, teamster, and union employee’s etc.
. Back up relief to heavy high volume PBX switchboard operator.
. Back up to Payroll and Presidents Secretary, and Labor Relations in their absence.
. Claims Assistant W/C and General Liability
Education
2002 Associate of Science Degree, Administration of Justice Degree
Certification
Skils
10 key by touch, customer service, medical terminology, bilingual in spanish.