Devonika WISE
Norfolk,VA
Summary
Seasoned Workers Compensation Adjuster with over 7 years of experience in claims processing, investigation, and resolution. Adept at managing complex cases, ensuring compliance with legal standards, and delivering high-quality client service. Demonstrated expertise in leadership and team management, with a strong focus on achieving company objectives and client satisfaction. Skilled in navigating complex insurance claims and providing thorough investigations to ensure fair settlements. Have experience coordinating with legal teams, policyholders, and insurance companies to manage claims efficiently. Known for strong analytical skills, ability to interpret policy details accurately, and effective communication that results in resolved disputes. Made significant impacts by streamlining claims processing procedures, enhancing customer satisfaction through timely resolutions.
Overview
12
12
years of professional experience
Work History
Workers Compensation Adjuster
CORVEL-VA
04.2023 - 03.2024
- Completing the 24-hour contact and adhering to all deadlines set by the carrier and/or the Department of Labor
- Timely filing of appropriate forms with the DOL to stay in compliance and avoid penalties
- Including EDIs and responding to 20 and/or 30-day orders
- Initiate an investigation by gathering facts and evidence with all interested parties including claimant and attorney and medical providers
- Developed case strategies for complex matters requiring litigation.
- Collaborated with various departments within an organization such as Human Resources, Risk Management, Legal Affairs.
- Analyzed trends in claim activity in order to identify areas needing improvement.
- Educated clients on best practices for minimizing risk associated with workplace injuries.
- Obtaining claimant wages and calculating AWW to payout TTD, TPD, PPD, and PTD payment
- Making sure the diary system is well noted for carrier examination by documenting all file activity and payment/settlement information
- Reviewing and requesting medical documentation to ensure current medical treatment is necessary and appropriate
- Supplying DME equipment and reviewing medical prior authorizations
- Interacting with Nurse Case Managers to make sure medical treatment is as accurate as possible
- Handling litigated claims and working with the assigned defense to resolute claims
- Adhering at DOL informal conferences and preparing position statements for carrier
- Writing reserve requests and presenting to the carrier for settlement/payout authority
- Investigated workers' compensation claims and evaluated the facts to determine coverage and liability.
- Conducted interviews with claimants, employers, medical providers and witnesses to obtain information related to a claim.
- Reviewed medical records and other documents to evaluate the nature and extent of disability or injury.
- Negotiated settlements with attorneys representing claimants in order to resolve disputes quickly and efficiently.
Sr. Federal Work Comp Adjuster
GALLAGHER BASSETT
01.2018 - 04.2023
- Investigates and adjusts claims, as well as directs outside defense counsel, experts, and other vendors in the claim-handling processes
- Complete appropriate contacts within 24 hours of assignment, and establish and maintain an appropriate diary for follow-ups
- Setting reserves and providing well-written reserve requests to carrier explaining the reasoning behind the requested reserves or settlement authority
- Demonstrated ability to comply with carrier reporting and threshold requirements by sending out 90-day reports to keep them updated with claim exposure
- Obtaining claimant wages and calculating AWW to payout TTD, TPD, PPD, and PTD payment
- Supervises outside vendors retained for investigations, such as completing the scheduling of IME's, background checks for TCN and social media checks
- Contacting the injured employee or OC to obtain a detailed account of the injury causes
- Review and manage medical treatment plan for injured workers cost containment, expert witnesses, and litigation management to ensure claims are being handled appropriately according to the applicable jurisdiction
- Make appropriate contacts to discuss a settlement; extend an offer to the appropriate party; document all file activity and payment/settlement information in file notes clearly outlining the basis for settlement
- Handle litigated claims including PTSD with War Hazards exposure and scheduled injuries
- Determine whether treatment is appropriate and causally related to the compensable injury
- Reviewing and approving 8i stipulations for settlements
- Filing proper paperwork including position statements and loss wages with the DOL in a timely manner
- Working with assigned defense to resolute claims
- Provided coverage opinions based on analysis of facts, law, policy language and endorsements.
- Developed strategies for mitigating risk exposure from large-loss cases.
- Participated in training sessions related to new policies or procedures.
- Conducted witness interviews to assist claim information gathering process.
- Adhering at DOL informal conferences, trials
- Interacting with case nurse managements to make sure the claim is handle as accurately as possible
- Working with outside vendors to help investigate the claim as accurate as possible
- Negotiated settlements with claimants, attorneys and other parties.
- Drafted correspondence related to claim investigations and settlements.
- Evaluated subrogation opportunities to identify recoverable funds.
Prior Authorization Specialist III - PART TIME
Anthem, Inc.
Virginia Beach, USA
11.2020 - 02.2022
- Skilled negotiator/mediator hand selected by company to handle high profile clients and customer escalations
- Multi-trained in multiple departments so I can assist company in all business needs
- Assist with new hire training
- Completed data entry of prescriptions sent in from prescribers, customers, and pharmacies
- Sorting and distributing incoming faxes to the proper member or department
- Using company resources to assist pharmacies, customers, and prescribers in a reasonable time to answer questions and concerns
- Reviewing medical documents making sure we have all the proper information accepted by HIPPA policies to initiate a pa for a member
- Being able to differentiate what drugs and medical codes are covered under a patient's insurance plan
- Reviewed medication requests for approval/denial from hospitals, doctor's office, and pharmacies
- Going over denial letters with member and prescribers and advising next steps for the appeal process
- Reviewing clinical criteria of a members plan with prescribers to better assist the member needs
- Collaborated with other departments to ensure the delivery of urgent requests to make sure they were received in a timely manner
- Analyzed, updated, and recorded data entry information for customers and prescriber's profile
- Accepted, checked, and routed new PA orders
- Reviewed prior authorization requests to ensure accuracy and completeness of required information.
- Verified patient insurance coverage, including eligibility, benefits and authorizations for medical services.
- Coordinated with other departments to obtain additional information needed for prior authorization.
- Processed appeals in a timely manner as per policy guidelines.
- Collaborated with internal staff members to resolve discrepancies or issues related to prior authorizations.
Team Leader, Claims Support III
DOMA TECHNOLOGIES
09.2015 - 01.2018
- Responsible for the delivery of the KPIs of the immediate team, including quality, productivity, and compliance parameters
- Delivers regular and timely coaching and feedback to the team members to enhance performance
- Ensures proper and timely dissemination of all processes and business updates to the team, based on client requirements
- Supervises the team members, identifying and addressing developmental issues, coaching opportunities, and recommending training interventions
- Responsible for the enforcement of organizational policies and procedures to ensure compliance
- Record and track Service Levels, Adherence Reports, and Attendance Reports using an Excel spreadsheet
- Approve timesheets
- Send weekly reports to my supervisors as well as my team members to ensure numbers are being met
- Obtaining and reviewing all medicals records and sending contents to the VA for veteran disability processing
- Provides medical release authorization forms to healthcare facilities to authorize the release of patient private medical records to obtain information needed for client claim
- Communicates with healthcare providers via phone, fax, and email
- Ability to interpret Department of Veterans Affairs Form
- Meets established productivity goals and quality standards of the company
- Assisted Office Manager with scheduling and organizing meetings, appointments, and events.
- Composed memos, emails, letters, reports and other documents as requested by the Office Manager.
- Prepared presentations in PowerPoint for internal meetings or external customers as required by the Office Manager.
- Developed and implemented recruiting plans to meet staffing goals.
- Conducted interviews with potential candidates, evaluated their qualifications and made hiring decisions.
- Collaborated with department managers to identify recruitment needs and develop job postings.
- Reviewed resumes and applications to determine which candidates met the position criteria.
- Source qualified candidates through online job boards, social media networks, referrals.
Prior Authorization Specialist III
Anthem Blue Cross BlueShield
Virginia Beach, USA
09.2012 - 09.2015
- Skilled negotiator/mediator hand selected by company to handle high profile clients and customer escalations
- Multi-trained in multiple departments so I can assist company in all business needs
- Assist with new hire training
- Completed data entry of prescriptions sent in from prescribers, customers, and pharmacies
- Sorting and distributing incoming faxes to the proper member or department
- Using company resources to assist pharmacies, customers, and prescribers in a reasonable time to answer questions and concerns
- Reviewing medical documents making sure we have all the proper information accepted by HIPPA policies to initiate a pa for a member
- Being able to differentiate what drugs and medical codes are covered under a patient's insurance plan
- Reviewed medication requests for approval/denial from hospitals, doctor's office, and pharmacies
- Going over denial letters with member and prescribers and advising next steps for the appeal process
- Reviewing clinical criteria of a members plan with prescribers to better assist the member needs
- Collaborated with other departments to ensure the delivery of urgent requests to make sure they were received in a timely manner
- Analyzed, updated, and recorded data entry information for customers and prescriber's profile
- Accepted, checked, and routed new PA orders
Education
Bachelor of Science - PSYCHOLOGY
Capella
ONLINE09-2024
High School -
GREAT BRIDGE HIGH SCHOOL
12.2011
Skills
- Claims processing and Handling
- Claims investigations
- Leadership
- Recruiting
- Customer Service
- Expert in communications
- Insurance Verification
- Case Management
- Documentation Review
- PTSD Care
- ICD-10
- Workers' Compensation
- Medical Records
- EDI
- Typing
- Workers' compensation law
- ICD-9
- Case coordination
- Policy investigations
- Financial Analysis
- Minimize exposure
- Fraud Detection
- Negotiation and mediation
- Cost Analysis
- Interviewing techniques
- Claims settlement
- Fraud identification
- Problem-solving aptitude
Timeline
Workers Compensation Adjuster
CORVEL-VA
04.2023 - 03.2024
Prior Authorization Specialist III - PART TIME
Anthem, Inc.
11.2020 - 02.2022
Sr. Federal Work Comp Adjuster
GALLAGHER BASSETT
01.2018 - 04.2023
Team Leader, Claims Support III
DOMA TECHNOLOGIES
09.2015 - 01.2018
Prior Authorization Specialist III
Anthem Blue Cross BlueShield
09.2012 - 09.2015
Bachelor of Science - PSYCHOLOGY
Capella
High School -
GREAT BRIDGE HIGH SCHOOL