Darelle DeMarco
Allenstown
Summary
Proven leader in claims management with extensive experience in claims auditing and investigation techniques. Enhanced team productivity and efficiency through effective coaching, achieving significant improvements in claims processing and customer satisfaction. Skilled in coverage interpretation and mentoring, consistently delivering results by reducing company exposure and maintaining high levels of client trust.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Claims Manager
AmTrust Financial Services, Inc, AFSI
03.2023 - Current
- Lead a team of adjusters, providing coaching and performance feedback for improved productivity.
- Complete regular audits of claim files ensuring accuracy in reserve amounts and adherence to established guidelines.
- Collaborated with other departments to improve overall organizational effectiveness in addressing client needs.
- Enhanced customer satisfaction with timely and accurate claims resolutions.
- Improved claims processing efficiency by implementing streamlined workflow procedures.
- Developed targeted strategies for reducing overall company exposure while maintaining customer satisfaction levels through effective risk mitigation practices within the claims department.
Claims Adjuster
AmTrust Financial Services, Inc, AFSI
07.2017 - 02.2023
- Conducted thorough investigations of complex insurance claims, gathering evidence and analyzing relevant documentation.
- Negotiated favorable settlements with claimants, attorneys, and other insurance carriers to minimize financial risk for the company.
- Mitigated risks and increased profitability with well-developed strategies for reducing future claims and costs.
- Maintained compliance with state regulatory requirements through meticulous documentation and adherence to company policies.
- Contributed to a positive work environment through active participation in team meetings and collaborating on cross-functional projects.
- Mentored junior adjusters on best practices and industry regulations, contributing to their professional growth and development.
- Achieved high customer satisfaction ratings by providing clear and timely communication throughout the claims process.
Claims Representative
Sedgwick
11.2016 - 06.2017
- Investigated workers compensation claims determining compensability and benefits due.
- Maintained reserve accuracy.
- Developed action plans for resolution.
- Coordinated early return-to-work to mitigate loss exposure.
- Worked productively in fast-moving work environment to process large volumes of claims.
- Processed assigned claims in a timely manner.
- Communicated claim action with claimant and client.
- Ensured claim files are properly documented and claims coding is correct.
- Maintained professional client relationships.
Claims Representative Trainee
Sedgwick
07.2016 - 10.2016
- Completion of designated classroom claims professional training program.
- Performed on-the-job training activities.
- Adjusted medical only and minor lost-time workers compensation claims.
- Processing disability claims of minimal disability duration under close supervision.
- Documenting claims files and properly coding claim activity.
- Communicating claim action/processing with claimant and client.
- Supported other claims examiners and claims Team Leads with larger or more complex claims as assigned.
- Participates in rotational assignments to provide temporary support for office needs.
Claims Assistant
Sedgwick
08.2015 - 06.2016
- Input and reviewed notes/diaries in claims management system as needed.
- Processed payments.
- Processed mail;handled filing, faxing and photocopying.
- Reviewed, prepared, created, and sent letters, reports, and forms.
- Answered and initiated telephone calls and provided customer service as required.
- Followed up with providers for upcoming medical appointments.
- Prepared medicals reports for providers for IME.
- Requested medical invoices and reports from providers pertaining to Workers Compensation claims.
- Requested and calculates employee wages.
- Completed projects as assigned including the preparation and distribution of computer reports.
Reimbursement Coordinator
Advantage Reimbursement
01.2015 - 07.2015
- Verified billing information from customers to generate claims.
- Verified patient eligibility.
- Performed Q.A. of charges.
- Tracked claims that were pending due to missing or incomplete information.
- Requested necessary documentation (i.e.: CMN, RX,authorization, etc.).
- Mailed claims to insurance companies within the individual insurance company's timely filing period.
- Created secondary claims and self-pay letters upon receipt of a primary insurance payment or denial.
- Reconcilliation of outstanding accounts.
Accounts Receivable Specialist
Physician Resources
01.2013 - 01.2015
- Reduced outstanding accounts receivable balances by diligently following up on overdue payments.
- Supported month-end closing activities by reconciling accounts, preparing reports, and analyzing trends in account performance.
- Ensured the accuracy of customer records in internal systems by updating contact information, payment terms, and other relevant data as needed.
- Prepared and mailed invoices to customers, processed payments, and documented account updates.
- Monitored accounts to verify compliance with payment terms and schedules.
- Negotiated payment arrangements with customers to establish timely receipt of payments.
- Increased efficiency of the collections process by implementing new strategies and procedures for tracking delinquent accounts.
- Reviewed accounts on monthly basis to assess aging and pursue collection of funds.
Education
Associate of Applied Science - Human Services
Hudson Valley Community College
Troy, NYCertificate - Health Claims Specialist
Seacoast Career Schools
Manchester, NHSkills
- Team leadership
- Claims Auditing
- Claims analysis
- Coverage and policy Interpretation
- Claims investigation and research
- Investigation techniques
- Coaching and Mentoring
Certification
Licensed in Texas and all New England States.
Timeline
Claims Manager
AmTrust Financial Services, Inc, AFSI
03.2023 - Current
Claims Adjuster
AmTrust Financial Services, Inc, AFSI
07.2017 - 02.2023
Claims Representative
Sedgwick
11.2016 - 06.2017
Claims Representative Trainee
Sedgwick
07.2016 - 10.2016
Claims Assistant
Sedgwick
08.2015 - 06.2016
Reimbursement Coordinator
Advantage Reimbursement
01.2015 - 07.2015
Accounts Receivable Specialist
Physician Resources
01.2013 - 01.2015
Associate of Applied Science - Human Services
Hudson Valley Community College
Certificate - Health Claims Specialist
Seacoast Career Schools
Licensed in Texas and all New England States.
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