Alodie Cooper-Sweet
Antioch,CA
Summary
Results-driven Future Medical Examiner specializing in workers' compensation with expertise in claim investigations and negotiations. Skilled in adjusting future medical claims to ensure timely processing and payment of benefits. Proven ability to reduce claim processing times while maintaining compliance with California labor code, leading to enhanced client satisfaction and lower loss ratios.
Overview
25
25
years of professional experience
Work History
Future Medical Examiner
Athens Administrators
Concord, California
02.2022 - Current
- Review daily diary for claim status
- Review medical reports to determine whether additional medical opinions are needed
- Calculate and maintain appropriate reserve on each file in accordance with life expectancy
- Object to unauthorized medical treatment
- Establish contact with employer to review issues
- Report to Excess carriers
- Make benefit payments
- Respond to inquiries from the employer, employee, doctors and attorneys
- Review legal correspondence and medical reports
- Evaluate and approve medical procedures and treatment
- Administer benefits and ensure appropriateness of all payments
- Review medical and legal bills for appropriateness
- Discuss appropriateness of medical treatment with medical case manager
- Negotiate settlement of claim, and liens
- Prepare and present reports to clients
- Close claims appropriately
- Help resolve client billing and payment inquiries
- Investigate complaints from injured workers
- Document and code the claim files and claims system with all relevant information
- Maintain and update action plans within specified time frames
- Provide customer service and support to clients and claimants
- Work collaboratively with attorneys
- Authorize and negotiate cost of medical treatment and supplies
Assistant Claims Examiner
Athens Administrators
Concord, CA
06.2012 - 02.2022
- Review and evaluate claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio
- Calculate wage statements and adjust disability rates as required
- Examine and investigate questionable claims to determine whether to delay for transfer claim to Senior Claims Examiners desk or to accept as an Medical
- Verify data used in claims to ensure that claims are valid and that are made according to company practices and procedures
- Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation
- Contact and interview claimants, doctors, medical specialists, or employers to get additional information
- Maintain claim files such as records of claims and an inventory of claims requiring detailed analysis
- Send benefit notices in a timely manner
- Prepare and attend claims review monthly and quarterly review with clients
- Work collaboratively with Senior Claims Examiners, Nurse Case Managers and other Assistant Claims Examiners
- Draft and submit Stipulated Awards and C & R's to employees and to WCAB
- Issue all indemnity payments and awards in a timely manner
- Keep dairy for Medical Only claims, delay, denial and indemnity payments dates.
- Paid and processed claims within designated authority level.
- Adhered to company and insurance client's guidelines in claims processes, estimate writing and claim closures.
- Entered claim transactions, payments, reserves, and other documentation.
Claim Assistant
Zurich North America Insurance
05.2005 - 10.2011
- Experience in Medical Only caseload Knowledge of California laws and regulations Designations: Workers' Compensation Administration and
- Workers' Compensation Claims Professional
- Scanning and importing documents, switchboard, logistics & EZAccess Sets up and enters new claims into claims management system
- Inputs and reviews notes/diaries in claims management system as instructed
- Processes payments
- Processes mail; handles filing, faxing and photocopying
- Reviews, prepares, creates, and/or sends letters, reports, and forms
- Answers and initiates telephone calls, sets up medical appointments, and may provide customer service as required
- Other activities/projects as assigned including the preparation and distribution of computer reports
- Supports the Total Performance Management initiative.
- Maintained case files from California, Arizona, and Montana
Claim Assistant Lead-Medical Only
Kaiser Permanente
Oakland, CA
04.2001 - 05.2005
- Manages a caseload typically involving claims of indemnity benefits with first time lost time, AOE/COE, 365 medical only issues, 90 days modified duties or claims of similar complexity
- Adjust, examine and approve claims for workers' compensation benefits
- Process and maintain records for workers comp agency Act as liaison between injured worker, agents, and all parties involved
- Process and complete initial investigation of 3-pt contact
- Obtain and evaluate claim information from client, so that the claim can be resolved
- Adhere to California Labor Code at all times
- Work with claims manger, loss control and Underwriting to facilitate claims review
- Processed claims for payment or forwarded to appropriate personnel for further investigation
- Collaborated with fellow team members to manage large volume of claims.
Education
Certificate - Workers Compensation
Self Insured Program
08-2022
Associate of Arts - Business Administration
Colorado Tech University
03-2012
Assistant Claims Examiner Designation -
Workers Compensation
01-2012
Workers Compensation Claims Professional Designation Certificate (WCCP) -
05-2008
Workers Compensation Claims Administration Certificate (WCCA) -
05-2008
Skills
- Workers' compensation claims
- Customer service and support
- Claims file management processes
- Benefit explanation
- Interviewing techniques
- Ensured compliance with industry standards by consistently updating protocols and procedures
- Workers' compensation knowledge
- Claim negotiation
- Benefit administration
- Medical claims processing
- Legal correspondence review
Timeline
Future Medical Examiner
Athens Administrators
02.2022 - Current
Assistant Claims Examiner
Athens Administrators
06.2012 - 02.2022
Claim Assistant
Zurich North America Insurance
05.2005 - 10.2011
Claim Assistant Lead-Medical Only
Kaiser Permanente
04.2001 - 05.2005
Certificate - Workers Compensation
Self Insured Program
Associate of Arts - Business Administration
Colorado Tech University
Assistant Claims Examiner Designation -
Workers Compensation