Angela Gaita
West Milford,NJ
Summary
Talented Claims Adjuster emphasizing effective time management, cost control and mediation. Self-motivated and customer-focused. Meticulous Claims Investigator effective at collecting and analyzing data used to devise fair and cost-effective settlements.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Sr. TPA Oversight Bodily Injury Adjuster
Berkshire Hathaway - GUARD Insurance Co.
Wilkes-Barre , PA
2022.04 - 2022.10
- Responsible for overseeing select TPAs for adherence to Guard claim handling standards
- Coordinate with internal parties and TPAs on data exchange
- Provided direction to the TPAs, regarding claims handling extended settlement & reserve authority up to $250,000.00
- Attended virtual Mediations, directed defense counsel on all policy limit demands
- Reviewed medical specials, police reports, liability, negligence type managed and determined appropriate settlements
- Participated in Microsoft Team meetings, claim reviews and audits
- Address issues with internal parties on TPAs audit findings for ultimate resolution plan.
- Conducted in-depth research on legal, medical, and policy issues related to bodily injury claims.
- Interpreted insurance policies to ensure proper application of coverage provisions in each particular case.
- Collaborated with colleagues across departments to identify potential solutions for challenging cases.
- Performed quality control checks on all claim files prior to submission for approval or closure.
- Investigated questionable claims to determine payment authorization.
Senior Resolution Manager
Gallagher Bassett
Mechanicsburg , PA
2021.07 - 2022.01
- Investigate, evaluate, dispose and settle moderate to complex commercial general liability with minimal supervision
- Evaluate coverage, liability damages and reserves for ultimate probable case exposure
- Adhere to Best Practices, in accordance with statutory, and regulatory requirements
- Comply with Medicare Secondary Payer Act
- Recognize carrier reporting and threshold requirements, per special handling and pursue excess insurance recoveries
- Review lease agreements and contracts to develop opportunities for tender and subrogation
- Participate in virtual mediation settlement conferences.
- Reviewed medical records and police reports to evaluate the merits of a claim.
- Assessed potential legal liabilities, negotiated settlements, and determined reserves.
- Conducted interviews with claimants, witnesses, experts and other parties involved in the claim process.
- Investigated liability claims to determine coverage and extent of damages.
- Analyzed complex documents such as contracts, policies, deeds and titles for accuracy and completeness.
- Collaborated with attorneys to develop strategies for defending against liability claims.
- Negotiated settlements on behalf of clients while protecting their interests.
- Advised clients on best practices for risk management and prevention of future liabilities.
- Developed relationships with various stakeholders involved in the claims process.
- Reviewed, evaluated and adjusted claims to promote fair and prompt settlement.
- Reviewed data to verify validity of claims and determine case management actions.
- Investigated questionable claims to determine payment authorization.
Liability Senior Claim Examiner
Broadspire Services, A Crawford Company
Berkeley Heights , NJ
2018.02 - 2020.06
- Review coverage, determine liability, initiate 24 hour contact and communicate with all involved parties
- Comply with Best Practices
- Investigate, secure documentation, evaluate exposure per jurisdictional parameters adjust reserves to ultimate exposure
- Handle moderate to complex commercial general liability, BI and PD claims
- Participate in person offsite settlement and mediation conferences
- Partner with defense counsel for proper litigation management and efficient claim resolution
- Review of lease agreements, contracts for tender and subrogation
- Comply with Medicare Secondary Payer act.
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Prepared various reports documenting findings and recommendations regarding claims resolution.
- Communicated with claimants, attorneys and other parties involved in the process.
- Participated in meetings with senior management team members to discuss trends in claims handling.
- Attended continuing education courses to stay abreast of best practices in the field.
- Ensured compliance with applicable state laws, regulations and standards of practice.
- Verified liability extent with reviews of police reports, medical treatment histories and other records.
- Discussed current cases and issues in claim committee meetings.
Claims Examiner
N.J. PROPERTY LIABILITY INSURANCE GUARANTY ASSOC.
Basking Ridge
2007.10 - 2017.06
- Investigated, evaluated, negotiated & settled standard - complex Work Comp, and Excess Medical Benefit Claims
- Managed 950 pending medical files while assisting Triage group with influx of Work Comp A&P insolvency files without compromising work quality
- Conducted file reviews, to ensure accuracy of claims, cost containment measures in place through audits, peer reviews, IME and vendor management.
- Analyzed and audited open claims to calculate additional payments owed.
- Participated in quality assurance activities such as peer reviews and audits.
- Gathered information from various third parties to determine claim acceptability.
- Processed appeals from denied claims according to established procedures while ensuring compliance with applicable laws and regulations.
- Investigated questionable claims to determine payment authorization.
- Completed required investigations on referred files within established timeframes.
- Conducted audits of claim files to ensure adherence to departmental standards.
- Obtained necessary information to complete proper evaluation of injury claims.
- Provided guidance to other staff members regarding claim processing rules and regulations.
- Researched complex billing errors that required an in-depth review of all available documentation before resolution could be reached.
- Communicated with personnel and legal counsel on claims involving litigation.
- Supervised independent adjusters to promote adherence to guidelines.
- Maintained up-to-date knowledge about changes in healthcare reform legislation affecting provider reimbursements.
- Reviewed medical records and documents to determine coverage eligibility of claims for insurance benefits.
- Investigated workers' compensation claims to determine eligibility and extent of coverage.
- Communicated with medical providers, claimants, lawyers and public officials to provide invested parties with claim information and facilitate necessary participation.
- Collaborated with legal counsel in the preparation of documents related to litigation proceedings involving workers' compensation claims.
Senior Risk Analyst
CRAWFORD INTEGRATED SERVICES
Fairfield
2003.01 - 2007.10
- Served as a claim liaison between Crawford Integrated Services, clients, insureds and brokers
- Ensured reporting by field offices on claims reserved above authority levels
- Evaluated reportable claim files to ensure proper investigation
- Provided claim supervision in support of the same at branch level
- Coordinate and consult with client/insured/broker on claim activity as required and set up claim reviews
- Management of litigation by direction and supervision of defense counsel and branch offices
- Authorized large settlements on reportable files.
- Collaborated with various departments within the organization to ensure effective implementation of risk mitigation strategies.
- Investigated suspicious transactions as part of fraud prevention efforts.
- Lead and executed risk management projects to identify deficiencies and possible corrective actions.
- Maintained risk identification programs to reduce potential losses from workers' compensation and general liability insurance issues.
- Reported findings on risk exposures to senior executives and board of directors.
- Used cost-containment tools safely and accurately to control risks.
Education
Bachelor of Arts (BA) - Psychology
RUTGERS UNIVERSITY
Skills
- Problem Solving & Critical Thinking
- Coverage Analysis & Investigations
- Negotiations & Settlements
- Litigation Management & Excel
- Microsoft Office
- Word Outlook
- Risk Management
- Coverage Assessments
- Medical Coding
- Insurance Fraud Expertise
Certification
- New Hampshire,
- Indiana,
- Connecticut,
- Florida
- Kentucky
Timeline
Sr. TPA Oversight Bodily Injury Adjuster
Berkshire Hathaway - GUARD Insurance Co.
2022.04 - 2022.10
Senior Resolution Manager
Gallagher Bassett
2021.07 - 2022.01
Liability Senior Claim Examiner
Broadspire Services, A Crawford Company
2018.02 - 2020.06
Claims Examiner
N.J. PROPERTY LIABILITY INSURANCE GUARANTY ASSOC.
2007.10 - 2017.06
Senior Risk Analyst
CRAWFORD INTEGRATED SERVICES
2003.01 - 2007.10
Bachelor of Arts (BA) - Psychology
RUTGERS UNIVERSITY
- New Hampshire,
- Indiana,
- Connecticut,
- Florida
- Kentucky
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