Brenda Veal
Chula Vista,CA
Summary
Detail-oriented Examiner with over 20 years of experience. Strong command of conflict resolution and negotiation combined with excellent customer service and claims handling skills. Willingness to take on added responsibilities to meet team goals.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Workers' Compensation Claims Adjuster
Sedgwick CMS
San Diego, CA
03.2023 - Current
- Manage complex workers' compensation claims from initiation to resolution, ensuring compliance with legal requirements.
- Evaluate medical records and documentation to determine claim validity and appropriate benefits.
- Collaborate with healthcare providers and employers to gather necessary information for claims processing.
- Implemented process improvements that enhanced claim review efficiency and reduced turnaround times.
- Receives claim, confirms policy coverage and acknowledgement of the claim
- Determines validity and compensability of the claim by investigating and gathering information regarding the claim and files necessary documentation with state agencies and self insured.
- Establishes reserves and authorizes payments within reserving authority limits if $100k.
- Ensures indemnity benefits are calculated correctly based on the wages received from the employer and that both payments and notices are sent timely to claimant to avoid a penalty.
- Develops and manages well documented action plans in Juris.
- Labels and documents incoming mail on file on a daily basis through the program SIR.
- Coordinates early return-to-work efforts with the appropriate parties
- Manages subrogation and litigation of claim as it applies
- Manages potential claim recoveries of all types
- Reports claims to the excess carrier when applicable
- Communicates claim status with the employer and claimant
- Adheres to client and carrier guidelines and participates in claims reviews as needed
- Develops and maintains professional customer relationships
- Complies with rules and regulations of applicable state
- Additional projects and duties as assigned
WORKERS COMPENSATION SPECIALIST
CorVel Corporation
San Diego, CA
12.2021 - 03.2023
- Receives claim, confirms policy coverage and acknowledgement of the claim
- Determines validity and compensability of the claim by investigating and gathering information regarding the claim and files necessary documentation with state agencies
- Establishes reserves and authorizes payments within reserving authority limits
- Develops and manages well documented action plans with the case manager and outcomes manager to reduce overall cost of the claim
- Coordinates early return-to-work efforts with the appropriate parties
- Manages subrogation and litigation of claim as it applies
- Manages potential claim recoveries of all types
- Reports claims to the excess carrier when applicable
- Communicates claim status with the customer and claimant
- Adheres to client and carrier guidelines and participates in claims review as needed
- Develops and maintains professional customer relationships
- Complies with rules and regulations of applicable state
- Additional projects and duties as assigned
CLAIMS ADMIN SPECIALIST II
Zenith Insurance Company
San Diego, CA
02.2016 - 12.2021
- Issue timely and accurate allocated payments paying specific attention to timeframes and due dates
- Calculate and issue Temporary disability payments, wage loss payments, and permanent disability payments within specified timeframes
- Send correct DWC notices in compliance with expected timeframes
- Review and label Documentum
- Process and identify medical treatment requests through Zencare and complete follow up requests daily
- Complete peer review packets by uploading medical records through Zencare to ensure that treatment decisions can be made timely
- Schedule medical appointments, transportation and interpreters for injured workers and send necessary paperwork to all parties ahead of time
- Review for accuracy, Examiner, Nurse or Attorney assignments prior to completion
- File legal documents for attorneys through the EAMS website and ensure quality assurance of these documents
- Assist nurses during the weaning process by sending out correct notices and completing the necessary paperwork
- Set up meetings for Examiners, Attorneys and nurses when needed
- This could include medical director staffing
- Answer phone calls for Examiners and respond to requests from injured workers, Employers and brokers timely
- Provide ongoing administrative support to Examiners
- Attorneys and Nurses by completing work status calls, processing & formatting correspondence, and completing all paperwork and follow up phone calls timely
- Perform any other specially assigned duties/tasks as they arise and complete all diaries within their specified time frames
- Applies principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions
- Work productively and harmoniously with others on a consistent basis
- Consistently maintain professional and appropriate demeanor
- Perform other duties/projects as assigned.
CLAIMS ASSISTANT/MEDICAL ONLY CLAIMS
San Diego Gas & Electric
San Diego, CA
11.2007 - 04.2010
- Under general supervision, maintained assigned caseload of medical only claims
- Worked with doctors and employees to keep lines of communication open and reach case resolution in a timely manner
- Met productivity objectives
- Responsible for meeting specific performance objectives
- Made disability and medical payments within given authority
- Input and monitor automatic disability schedule payments and cancellations
- Timely manage assigned tasks with system diary
- Arrange medical examinations; prepare physician cover letter with assistance or approval of examiners
- Reserve authority of up to $3500.00 as established by management
- Assisted in the set-up of Non-Occupational claims
- Assisted in the IRS verification of vendors for payment approval and submission
- Assisted four specialists that handle Workers' Compensation claims and Non-Occupational claims
- Ensured customers receive accurate, timely and courteous service
- Completed transfers for employees to or from long term disability
- Knowledge and proficiency in EAMS
- Proficient in using computer to include claims information, coverage, DWC notices, and payment verification
- Strong knowledge of Word, Outlook, iVOS, Mainframe and Portal
CLAIMS ADJUSTER
Berkshire Hathaway Homestate Companies
San Diego, CA
08.2007 - 11.2007
- Under general supervision, maintained assigned caseload of medical only claims
- Worked with doctors and claimants to keep lines of communication open and reach case resolution in a timely manner
- Settlement/reserve authority of up to $2500.00 as established by management.
- Communicated with policyholders, injured workers and others in a professional and timely matter
- Analyzed claims, sets reserves, determines compensability
- Acted as a trainer/mentor for less experienced members of the claim technical staff
CLAIMS ASSISTANT/MEDICAL ONLY CLAIMS
San Diego Gas & Electric
San Diego, CA
11.2004 - 07.2006
- Under general supervision, maintains assigned caseload of medical only claims
- Works with doctors and claimants to keep lines of communication open and reach case resolution in a timely manner
- Met productivity objectives
- Responsible for meeting specific performance objectives
- Make disability and medical payments within given authority
- Input and monitor automatic disability schedule payments and cancellations
- Timely manage assigned tasks with system diary
- Arranged medical examinations; prepare physician cover letter with assistance or approval of examiners.
Education
GED - undefined
Santana High School
Santee, CA01.1995
Skills
Claim Validity Determination
Employee Relations
Legal Documents
Workers Compensation
Investigation Documentation
Compensation and Benefits
Administering Claims
HIPAA Guidelines
Certification
Claim Adjuster designation, Corvel Corporation - 6/30/22-6/30/24
Timeline
Workers' Compensation Claims Adjuster
Sedgwick CMS
03.2023 - Current
WORKERS COMPENSATION SPECIALIST
CorVel Corporation
12.2021 - 03.2023
CLAIMS ADMIN SPECIALIST II
Zenith Insurance Company
02.2016 - 12.2021
CLAIMS ASSISTANT/MEDICAL ONLY CLAIMS
San Diego Gas & Electric
11.2007 - 04.2010
CLAIMS ADJUSTER
Berkshire Hathaway Homestate Companies
08.2007 - 11.2007
CLAIMS ASSISTANT/MEDICAL ONLY CLAIMS
San Diego Gas & Electric
11.2004 - 07.2006
GED - undefined
Santana High School