Cynthia Pelton
Las Vegaa,NV
Summary
Effective leader in Workers Compensation Claims Management known for strong team collaboration, adaptability to changing needs, and delivering measurable results.
Overview
33
33
years of professional experience
Work History
Executive Business Strategist
Nexus Wound Consultants /Opteo Health
01.2024 - Current
- Implementing innovative business strategies for multiple projects.
- Point of contact for all executives and external partners.
- Office manager/HR liason for onsite Las Vegas team and overseas operations.
- Conducted thorough reviews of operations to devise and deploy improvement strategies.
- Reviewed internal systems and organized training plans to address areas in need of improvement.
- Evaluated organizational structures and implemented best practices in change management, fostering a culture of continuous improvement within the company.
- Interviewing, hiring, training, discipline of billing and operations staff.
Director of Claims
Markel Insurance Company
05.2018 - 01.2024
- Provided leadership of the West Region Workers Compensation Claims Department (CA, AZ, NV, AK, CO, UT, HI, NM, OR, ID, MT).
- Provided leadership and technical expertise to a team of Claims Managers, Claims Supervisors, Sr. Level Examiners and Admin staff.
- Ensured compliance with company budgeting, reserving and settlement philosophy.
- Oversaw TPA operations in AK, OR ID, MT.
- Maintained compliance with industry regulations, ensuring all claims processes adhered to legal requirements and company policies.
- Improved claim resolution efficiency by implementing new processing systems and protocols.
- Reviewed complex claims cases, providing expert guidance to adjusters on proper handling techniques.
- Monitored team performance, enforcing compliance with corporate claims processes and procedures.
Claims Manager
Markel Insurance Company
05.2008 - 06.2018
- Determined proper course of action for complex claims management for CA, NV, HI, CO, UT, AK, AZ, NM claims.
- Served as Litigation Manager for CA claims.
- Implemented quality assurance measures, monitoring staff performance and providing constructive feedback for continuous improvement efforts.
- Developed training materials to ensure consistent handling of claims across the department.
- Improved claims processing efficiency by implementing streamlined workflow procedures.
- Managed a team of Sr Level Examiners, providing coaching and performance feedback for improved productivity.
Senior Claims Examiner /Team Lead
Safeway
11.2003 - 05.2008
- Handled high-profile CA workers compensation cases professionally, maintaining confidentiality while achieving satisfactory resolutions.
- Prepared detailed reports on claim activity for management review, highlighting areas for improvement.
- Mentored new hires during their onboarding process, sharing insights from years of experience as a Senior Claims Examiner.
- Reviewed policy coverage details meticulously, ensuring accurate determination of benefits payable in each case.
- Collaborated with legal counsel on complex claims, ensuring compliance with regulatory guidelines.
- Coordinated with medical professionals to obtain necessary documentation for evaluating injury claims accurately.
- Maintained up-to-date knowledge of industry trends and legislative changes, ensuring accurate claim evaluations.
- Provided exceptional customer service by empathetically addressing claimants'' concerns and effectively explaining the claims process to them.
Senior Claims Examiner
Innovative Claims Solutions
01.2000 - 11.2003
- Handled high-profile cases professionally, maintaining confidentiality while achieving satisfactory resolutions.
- Reviewed policy coverage details meticulously, ensuring accurate determination of benefits payable in each case.
- Prepared detailed reports on claim activity for management review, highlighting areas for improvement.
- Mentored new hires during their onboarding process, sharing insights from years of experience as a Senior Claims Examiner.
Claims Examiner
Fremont Comp Insurance Company
01.1999 - 01.2000
- Conducted thorough investigations of mid level claims, gathering relevant documentation and interviewing witnesses when necessary.
- Utilized analytical skills to evaluate medical bills for accuracy and appropriateness of charges before approving payments as part of the claims process.
- Maintained detailed records of all claims activities, ensuring compliance with regulatory requirements and company policies.
- Provided exceptional customer service by empathetically addressing claimants'' concerns and effectively explaining the claims process to them.
Claims Examiner
Cigna
02.1995 - 01.1999
- Conducted thorough investigations of medical only and mid level lost tiem claims, gathering relevant documentation and interviewing witnesses when necessary.
- Utilized analytical skills to evaluate medical bills for accuracy and appropriateness of charges before approving payments as part of the claims process.
- Maintained detailed records of all claims activities, ensuring compliance with regulatory requirements and company policies.
- Provided exceptional customer service by empathetically addressing claimants'' concerns and effectively explaining the claims process to them.
Claims Assistant
Kemper Insurance
01.1992 - 02.1995
- Prepared files, letters and notices.
- Provided exceptional customer service through clear communication, empathy, and proactive problem-solving during difficult situations.
- Improved customer satisfaction levels by providing timely, accurate, and empathetic support during the claims process.
- Continuously improved personal performance by seeking feedback from peers, examiners supervisors, and claimants for self-improvement and growth.
Education
Associate of Science - Business
American River College
Sacramento, CASelf Insured Certification
State of California
Workers Compensation Claims Professional
Insurance Education Association
Skills
- Claims management expertise
- Team building and motivation
- Effective communication techniques
- Decision-making confidence
Timeline
Executive Business Strategist
Nexus Wound Consultants /Opteo Health
01.2024 - Current
Director of Claims
Markel Insurance Company
05.2018 - 01.2024
Claims Manager
Markel Insurance Company
05.2008 - 06.2018
Senior Claims Examiner /Team Lead
Safeway
11.2003 - 05.2008
Senior Claims Examiner
Innovative Claims Solutions
01.2000 - 11.2003
Claims Examiner
Fremont Comp Insurance Company
01.1999 - 01.2000
Claims Examiner
Cigna
02.1995 - 01.1999
Claims Assistant
Kemper Insurance
01.1992 - 02.1995
Associate of Science - Business
American River College
Self Insured Certification
State of California
Workers Compensation Claims Professional
Insurance Education Association
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