Anne Caruso

POSITION SUMMARY: Under minimal supervision manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines.

This position requires considerable interaction with clients, claimants on the phone, and with management, other Claims Examiners, and other TRISTAR staff in the office.

DUTIES AND RESPONSIBILITIES:

• Handle loss time Workers’ Compensation claims
• The ability to prepare a formal captioned report on claims meeting client requirements
• Ability to effectively communicate in a professional manner
• Assist employers and their employee’s understand the WC process
• Investigate, evaluate, determine compensability, pay benefits timely as required and comply with all statutory requirements
• Determine compensability of claims and administer benefits, based upon state law and in accordance with established Company guidelines
• Manage medical treatment and medical billing, authorizing as appropriate
• Refer cases to outside defense counsel
• Communicate with claimants, providers and vendors regarding claims issues
• Computes and set reserves within Company guidelines
• Settle and/or finalize all claims and obtains authority as designated
• Maintains diary system for case review and documents file to reflect the status and work being performed on the file
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EQUIPMENT OPERATED/USED: Computer, 10-key, fax machine, copier, printer, and other office equipment.

• SIP Certified - pre-designated hours complete; Manage all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines
• Analyze California Workers Compensation claims on behalf of our valued clients to determine benefits due, while ensuring ongoing adjudication of claims within service expectations, industry best practices
• Analyzing and processing claims through well-developed action plans to an appropriate and timely resolution by investigating and gathering information to determine the exposure on the claim
• Negotiating settlement of claims within designated authority
• Communicating claim activity and processing with the claimant and the client
• Reporting claims to the excess carrier and responding to requests of directions in a professional and timely manner
• Manages the litigation process; ensures timely and cost-effective claims resolution
• Ensures claim files are properly documented and claims coding is correct
• Initiates and conducts investigation in a timely manner
• Determine compensability of claims and administer benefits, based upon state law and in accordance with established Company guidelines
• Manage medical treatment and medical billing, authorizing as appropriate
• Refer cases to outside defense counsel
• Communicate with claimants, providers and vendors regarding claims issues
• Computes and set reserves within Company guidelines
• Settle and/or finalize all claims and obtains authority as designated
• Maintains diary system for case review and documents file to reflect the status and work being performed on the file
• Communicate appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety-related concerns.
• Investigated discrepancies in claims and resolved issues with customers via telephone or written correspondence.

• Coverage verification, policy interpretation, liability investigation and evaluation of personal auto claims
• Take recorded statements from Insureds and Claimants, gather evidence, set up vehicle evaluations
• Negotiate with towing facilities on storage fees, request police reports, settle liability
• Issue payments, conduct thorough investigation of the claim, and settle claims
• Accurately reserve for each exposure
• Maintain compliance with the Department of Insurance in the applicable state
• Evaluate the claim for possible fraud indicators
• Review and evaluate medical and loss wage documentation
• Identify subrogation potential in all files handled

• Processed Medical Billing to Health Insurance Companies
• Appealed Insurance Denials
• Reduced Collectibles by 15 days resulting in greater revenue
• Followed up on appeals to be sure company was paid in a timely manner
• Extensively researched accounts
• Communicated to patients and other departments to resolve issues
• Project Management - worked reports to resolve billing issues
• Worked with Payers, such as Medicare, Medicaid, Managed Care, Commercial, Liability, and Workers' Compensation
• Followed HIPPA guidelines
• Maintained compliance with local, state, or federal guidelines as it relates to job duties
• Assisted Management in training new employees and in encouraging areas of improvement

• Worked in claims and benefits department
• Explained patients' benefits, deductibles, out of pocket, coinsurance, and copays
• Analyzed claims and clarified "Explanation of Benefits Summary" to members
• Tracked + recorded calls
• Followed-up on accounts to ensure they needed fewer reasons to contact
• Received an award for 100% positive experience on customer surveys on a monthly basis

• Trained employees in communication, listening skills, how to sell, general company guidelines, and how to build rapport with one another + clients
• Wrote + coordinated training sessions
• Monitored calls for staff's sales attempts, courtesy and guidelines used in company
• Analyzed results to track progress, sales, and time on call
• Worked with HR to meet employees' personal issues, work issues, attendance, FMLA, Disability, and ergonomic requests