Evelyn Ortiz
Tampa,FL
Summary
Ms. Ortiz is a quick learner and loves a challenge in the workplace. She is a self-starter and has the ability to work in a team setting or alone with ease.
Insurance Adjuster skilled in investigating and analyzing liability concerning personal, casualty or property loss. Proven history of leveraging excellent negotiation skills to facilitate settlements. Excellent communication skills demonstrated through 15 years of experience interviewing specialists, witnesses and claimants to compile information.
Overview
27
27
years of professional experience
1
1
Certification
Work History
Claims Manager Investigator
Delta Group
05.2017 - Current
- I work with Insurance Claim Adjusters and I Investigate many Hospitals and numerous facilities within the U.S
- To gather patient information due to work injury
- This information is put on a Canvass and uploaded into a Database Application
SIU Investigator
Avis Budget Group
06.2010 - 09.2016
- Investigated potential fraudulent activity
- Worked closely with NICB and IBC agents to pursue perpetrators of insurance fraud
- Cooperated with Ontario Rings Investigation Unit and Toronto Police law enforcement community to help put fraud perpetrators out of business
- Trained claims adjusters and examiners to look for 'red flags', or indicators that fraud might be occurring
- Review initial referral; evaluate claim and underwriting information to identify appropriate resource and investigative strategies
- Perform objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy
- Maintain and ensure accurate and timely documentation in the SIU tracking database
- Ability to handle multiple priorities/projects in a fast-paced professional environment
- Conducted an In-person clinic inspection in an active fraud ring investigation
- Interviewed claimants involved in fraud ring at the plaintiff attorney office
- Demonstrate performance in meeting time-sensitive deadlines with minimal supervision
- Interviewed subjects, targets and witnesses for information verification and corroboration
- Collaborated with examiners, legal staff, the Attorney General's office and other law enforcement agencies of the investigation action plan and recommendations on further action as needed
- Coordinated the EUO process for the PIP team and defense counsel
PIP Examiner II
Avis Budget Group
04.2008 - 06.2010
- Reduced loss ratios through fair and prompt processing of claims
- Obtained relevant evidence and information regarding suspicious claims
- Interviewed claimants, medical specialists and employers to determine pertinent claim information
- Managed a caseload of 350 clients each quarter
- Conducted interviews, gathered detailed information
- Investigated any potentially fraudulent claims with a focus on thoroughness, quality and cost control
- Mentored 6 new members of the claim staff
- Developed connections with local fraud bureaus, district attorneys' offices and professional associations
- Contacted injured parties and legal representatives to negotiate final settlements for claims
- Explained premiums owed to policyholders, agents and underwriters
- Completed required investigations on referred files in a timely manner
- Drafted statement of loss to summarize damages, payments and underlying policy coverage
- Kept up-to-date on changes in regulations for deductibles and collections
TCR2 Examiner
Geico
01.2004 - 01.2007
- Investigated claims against insurance for personal, property loss and damages
- Presented cases and participated in their discussion at claim committee meetings
- Verified and analyzed data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures
- Supervised claims adjusters to ensure that adjusters had followed proper methods
- Investigated, evaluated and settled claims, applying technical knowledge and human relations skills to effect
- Maintained claim files, such as records of settled claims and an inventory of claims requiring detailed analysis
- Responded to written and telephone requests for bilingual customers
- Resolve claims by investigating losses negotiating settlements
- Examine claim forms, policies and endorsement, client instructions and other records to determine liability
Personal Injury Protection Specialist II
Geico
01.1998 - 01.2004
- Research and responds to complex customer communications, concerns, conflicts or issues
- Summarizes documents and enters into claim system notes, documenting a claim file with notes, evaluations and decision-making process
- Utilized analytic tools or SIU field intelligence to identify complex claims for investigation and/or for support in the evidence of the fraud and damages
- Conducted thorough investigations of complex that are potentially fraudulent to determine if payment is warranted
- Validate that the information provided and obtained through investigation is true and accurate and follows up on all possible leads
- Conducted complex online data application searches, research, and evaluation
- Review investigations with fraud outcomes to validate whether denial is appropriate
- Update files with investigation outcome, and when no fraud or insufficient evidence is found, returns file to MCO for further handling and settlement
- Entered SIU claim data information into multiple SIU systems
- Made claim decisions regarding complex investigations, and pursues restitution
Education
Some College (No Degree) - Business Administration And Management
Baruch College
New York, NYSkills
- Multi line phone
- Customer Service
- Organization
- Attention to Detail
- Training
- PLUS (PC Literate User Specialist)
- Team/includes pc software and program troubleshooting
- Team training
- Excellent communication skills
- Claims investigation and research
- Investigation techniques
Accomplishments
- Recipient of the Toronto Police Project Whiplash Award in May, 2015 for investigative work leading to the collaboration and communication in the success of Project Whiplash, an investigation into organized insurance crime activity including staged collision and associated injury claims.
Certification
True, 01/14/24, Evelyn Ortiz
Additional Information
In 2013, honored by The Insurance Bureau of Canada., In 2015, received a recognition letter from Avis Budget Group Litigation Manager., The National Insurance Crime Bureau accepted 16 of my questionable claims submission.
Applications
- Abacus
- NICB Forewarn Alerts
- ISO Claim Search
- Damage Manager Portal
- Casetrack
- G4S
- ZipCar Website
- Accurint
Languages
Spanish
Professional Working
Timeline
Claims Manager Investigator
Delta Group
05.2017 - Current
SIU Investigator
Avis Budget Group
06.2010 - 09.2016
PIP Examiner II
Avis Budget Group
04.2008 - 06.2010
TCR2 Examiner
Geico
01.2004 - 01.2007
Personal Injury Protection Specialist II
Geico
01.1998 - 01.2004
Some College (No Degree) - Business Administration And Management
Baruch College
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