HOLLY MILLER
Clearwater,Florida
Summary
Experienced Senior Claims Examiner with 20 years of experience in Workers' Compensation. Excellent reputation for resolving problems and improving customer satisfaction.
Overview
23
23
years of professional experience
Work History
Senior State Fund Claims Examiner
Sedgwick (formerly CareWorksComp)
Dublin, OH
09.2017 - Current
- Continually analyze workers’ compensation claims in order to produce a plan of action that will yield the best financial outcome for the customer
- Initiate and implement workers’ compensation cost control strategies for a designated group of Ohio employers
- Cost control strategies include:
- Claim investigation
- Salary continuation
- Light duty or transitional work
- Lump sum settlement
- Handicap reimbursement
- Independent medical examinations
- Awareness of BWC discount programs
- Vocational rehabilitation
- Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
- Analyzed information gathered by investigation and reported findings and recommendations.
- Worked with private investigators and attorneys on preparation of evidence, witness statements and other documentation in preparation for trial.
- Collected evidence to support contested claims in court.
- Evaluated original investigation reports and documents to resolve secondary concerns.
- Followed up on potentially fraudulent claims initiated by claims representatives.
- Directed and coordinated various investigations conducted by field investigation team.
- Identified suspicious losses and contacted vendor for investigative assistance.
- Organized, planned, and documented materials for OH workers' compensation claims.
- Analyzed information gathered by investigation and report findings and recommendations.
- Maintained claims data in Team systems.
- Reviewed new files to determine current status of injury claim and to develop plan of action.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Researched claims and incident information to deliver solutions and resolve problems.
- Examined claims forms and other records to determine insurance coverage.
- Conducted day-to-day administrative tasks to maintain information files and process paperwork.
Account Manager
The Ohio Manufacturers’ Association
Columbus, OH
09.2015 - 07.2017
- Managed account of business for individualized clients
- Handled every aspect of claims, from initial filing, to every issue of the claim and then closure
- Worked directly with the employer, their attorneys, The Bureau of Workers’ Compensation, MCO’s and providers to assure the best outcome for the client
- Claims management
- Hearing preparation and attendance
- Rate evaluation and analysis
- Settlement evaluation
- Handicap reimbursement
- Client acquisition and retention
- Oversaw new business development and customer servicing.
- Built and strengthened long-lasting client relationships based on accurate price quotes and customer-centric terms.
- Addressed problems with accounting, billing and service delivery to maintain and enhance client satisfaction.
Senior State Fund Claims Examiner
Sedgwick (formerly CareWorksComp)
Dublin, OH
01.2005 - 09.2015
- Continually analyze workers’ compensation claims in order to produce a plan of action that will yield the best financial outcome for the customer
- Initiate and implement workers’ compensation cost control strategies for a designated group of Ohio employers
- Cost control strategies include:
- Claim investigation
- Salary continuation
- Light duty or transitional work
- Lump sum settlement
- Handicap reimbursement
- Independent medical examinations
- Awareness of BWC discount programs
- Vocational rehabilitation
- Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
- Analyzed information gathered by investigation and reported findings and recommendations.
- Worked with private investigators and attorneys on preparation of evidence, witness statements and other documentation in preparation for trial.
- Collected evidence to support contested claims in court.
- Evaluated original investigation reports and documents to resolve secondary concerns.
- Followed up on potentially fraudulent claims initiated by claims representatives.
- Directed and coordinated various investigations conducted by field investigation team.
- Identified suspicious losses and contacted vendor for investigative assistance.
- Organized, planned, and documented materials for OH workers' compensation claims.
- Analyzed information gathered by investigation and report findings and recommendations.
- Maintained claims data in Team systems.
- Reviewed new files to determine current status of injury claim and to develop plan of action.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Researched claims and incident information to deliver solutions and resolve problems.
- Examined claims forms and other records to determine insurance coverage.
- Conducted day-to-day administrative tasks to maintain information files and process paperwork
Therapy Services Coordinator
CareWorks (now Sedgwick MCO)
Dublin, OH
01.2004 - 01.2005
- Timely and efficiently coordinate all VocWorks, Ltd
- Therapy services with Physical and Occupational
- Therapists internally with external customers to ensure services are provided and exceed customer expectations
- Obtain, market and coordinate all therapy-based referrals such as: functional capacity exams, on site OT/PT, transitional work, ergonomic assessments and on site job analysis
- Serving as the primary contact for the VocWorks’ therapists; Provided medical information, contacting providers, employers and injured workers to expedite services in a timely, efficient manner
- Communicate with VocWorks’ therapists as well as all parties of the claim during the entire referral process and send reports when completed to these parties within an expected timeframe
- Instrumental in establishing initial requirements of this new position created to manage therapy referrals
- Expanded title and job duties from FCE Coordinator to Therapy Services Coordinator within two weeks of starting position, per request of internal customers
- Designed forms and databases to help ensure a smooth operation and to maintain accurate marketing information
- Received numerous positive emails and phone calls from highly satisfied customers of “can-do” attitude leading to many more therapy referrals and customer satisfaction.
- Initiated contact with appropriate service providers to request referrals and followed up to confirm appointments.
- Developed productive working relationships with churches, schools, government agencies and charitable organizations.
- Designed individualized service plans that took into account clients' goals and preferences.
- Upheld client satisfaction by designing accurate and detailed timelines for workers' compensation services and alerting clients of changes.
- Contributed to development, implementation and execution of maintenance programs.
- Analyzed account information to improve and optimize customer relations, resulting in reaching our monthly goals.
- Evaluated final results to determine quality levels and isolate root causes of any identified faults.
Case Specialist
CareWorks (now Sedgwick MCO)
Dublin, Ohio
06.2002 - 01.2004
- Communicate effectively with employers, injured workers, physicians, attorneys, third party administrators and the Ohio Bureau of Worker’s Compensation to mediate and manage worker’s compensation claims
- Coordinate resources with employers to effectively medically manage their stable claims, while ensuring a successful recovery and return to work while resolving customer issues as necessary
- Serve as primary contact and resource for several “Tier A employers” to provide excellent customer service while developing relationships to ensure customer retention
- Process medical treatment requests in accordance with established BWC and CareWorks’ guidelines
- Monitor, identify and refer claims that were in need of vocational rehabilitation and transitional work services while working closely with BWC certified physicians
- Serve as billing mentor, Team 7-8 assisting peers with questions or concerns regarding billing issues and attend monthly provider update meetings with other teams within thecompany
- Chosen to assist team members as vocational rehabilitation mentor for Team 7-8 by assisting peers with possible vocational rehabilitation referrals by checking TT reports, claims and deciding if an injured worker if feasible for this service
- Generate and maintain the highest number of vocational rehabilitation referrals within Team 7-8 from
Customer Service Representative
CareWorks (now Sedgwick MCO)
Dublin, OH
12.2001 - 06.2002
- Implement customer expectations and needs in a call center environment by providing information to injured workers, Third Party Administrators, providers and the Bureau of Worker’s Compensation
- Maintain customer satisfaction by gathering data and answering questions via telephone or in writing concerning injured worker’s claims or billing issues
- Demonstrate positive communication skills and manage difficult situations in a professional manner, therefore receiving four compliments within the first 90 days with CareWorks
- These compliments have come from providers, employers and internally
- Acquired an excellent working knowledge of all policies, procedures and workflow related to
- Customer Service
- Clearly understand department performance measures and the importance of maintaining ASA and ABA rates to meet performance measures
- Chosen to handle employer’s calls during Open Enrollment in May, 2002, resulting in exceeding all other Managed Care Organizations
- Incentive based on average speed of answer, promptness and call volume, resulting in first place in August
- Answered customer telephone calls promptly to avoid on-hold wait times.
- Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
- Answered constant flow of customer calls with minimal wait times.
- Offered advice and assistance to customers, paying attention to special needs or wants.
- Responded to customer requests for products, services and company information.
- Provided primary customer support to internal and external customers.
- Delivered exceptional customer service to every customer by leveraging extensive knowledge of products and services and creating welcoming, positive experiences.
- Investigated and resolved customer inquiries and complaints quickly.
- Responded proactively and positively to rapid change.
- Exhibited high energy and professionalism when dealing with clients and staff.
- Delivered prompt service to prioritize customer needs.
- Met customer call guidelines for service levels, handle time and productivity.
- Educated customers about billing, payment processing and support policies and procedures.
- Responded to customer requests, offering excellent support and tailored recommendations to address needs.
- Promoted superior experience by addressing customer concerns, demonstrating empathy and resolving problems swiftly.
- Trained new personnel regarding company operations, policies and services.
- Developed highly empathetic client relationships and earned reputation for exceeding service standard goals.
- Trained staff on operating procedures and company services.
- Effective liaison between customers and internal departments.
- Sought ways to improve processes and services provided.
- Increased efficiency and team productivity by promoting operational best practices.
- Facilitated inter-departmental communication to effectively provide customer support.
- Implemented and developed customer service training processes.
Customer Reference Program Specialist
Sterling Commerce
Dublin, Ohio
01.2000 - 01.2001
- Consistently exceeded company requirements for customer reference provider contacts on weekly basis, utilizing Access database and sales intranet tracking system, thereby contributing to revenue generation of $650,000 per month
- Created a systematized sequel server Access database, which merged existing databases into one, therefore enhancing customer information to be web accessible for sales and marketing
- Regularly promoted reference program through presentations to sales, marketing and customer service launching a new internal rewards offering, which increased leads submitted by two-thirds
- Interacted with sales and marketing to provide information on reference accounts, such as customer profiles, including software and hardware configurations, special contacts and customer usage history, resulting in the ability to identify and ensure a lasting relationship with customers
- Gauged customer satisfaction through phone calls and maintained Access database of highly satisfied customers to provide references to prospects for Sterling Commerce’s products and services.
- Maintained regular communication between departments via email and phone calls to coordinate program logistics.
- Established goals and created action plans to achieve goals.
- Received incoming phone calls and contact form submissions and provided timely responses to inquiries.
- Developed, coordinated and administered the Customer Reference Program program.
- Entered data in Excel system and handled database maintenance.
- Organized and managed program development from conception through successful execution.
- Designed program implementation and maintenance plan.
Property & Casualty Agent
American Family Insurance Co
01.1999 - 01.2000
- Serviced existing clients and developed new sales primarily through cross selling with agent
- Achieved sales goals through leads and referrals
- Helped protect customers by offering insurance and financial products that would meet their needs
- Conduct needs-based customer policy reviews and updated property and/or casualty coverage
- Provided accurate and timely inspections for commercial and/or residential properties.
Property & Casualty Agent
Prudential Financial Insurance Company
Columbus, OH
01.1998 - 01.1999
- Serviced existing clients and developed new sales primarily through cross selling with agent
- Achieved sales goals through leads and referrals
- Helped protect customers by offering insurance and financial products that would meet their needs
- Conduct needs-based customer policy reviews and updated property and/or casualty coverage
- Provided accurate and timely inspections for commercial and/or residential properties.
- Maintained original leases and renewal documents in digital and hardcopy format for property management office.
- Verified income, assets and expenses and completed file tracking sheet for each applicant.
- Monitored timely receipt and reconciliation of rent collections in accordance with landlord and resident statutes.
- Evaluated and recommended changes in rental pricing strategies to remain competitive in market.
- Communicated regularly with key on-and off-site tenant contacts to achieve satisfaction with facility and services.
- Developed, reviewed and submitted property operating and capital budgets.
Education
No Degree - Prep Courses For Dental Hygiene
Lima Technical College
Lima, OhioElementary Education and General Coursework - Prep Courses For Elementary Education
Bowling Green State University
Bowling Green, OHSkills
- Client Interviewing
- Claims Evaluations
- Claim for analysis
- Carrier Policies
- Identifying Errors
- Cost Control
- Legal Documentation
- Claim Validity Determination
- Customer Satisfaction
- Administering Claims
- Evidence Preservation
- Service Quality
- Filing Appeals
- Special Projects
- Microsoft PowerPoint
- Defense Strategy
- Injury Evaluation
- Diagnostic Codes
- Final Reviews
- Outpatient Procedures
- Outgoing Phone Calls
- Insurance Policy Coverage Knowledge
- Applications Knowledge
- Status Updates
- Fraudulent Claims Investigation
- Reserves Recommendations
- Report and Records Review
- Case Analyzation
Systems
I have utilized the following systems: Microsoft Access, Excel, Word, Works, Powerpoint, Outlook Express, Lotus Notes, TEAM, RightFax, Client Database System, Mitel, BWC's Website, Industrial Commission's website, Google Chrome, Microsoft Explorer, Acrobat Reader, Word to PDF, Compensate, Converter, Citrix, Citrix Receiver, Cute PDF Professional, Outlook Express, OneDrive, Powerpoint, Skype, Snip & Sketch, Word, Internet Explorer, Cisco & Acrobat Reader.
Timeline
Senior State Fund Claims Examiner
Sedgwick (formerly CareWorksComp)
09.2017 - Current
Account Manager
The Ohio Manufacturers’ Association
09.2015 - 07.2017
Senior State Fund Claims Examiner
Sedgwick (formerly CareWorksComp)
01.2005 - 09.2015
Therapy Services Coordinator
CareWorks (now Sedgwick MCO)
01.2004 - 01.2005
Case Specialist
CareWorks (now Sedgwick MCO)
06.2002 - 01.2004
Customer Service Representative
CareWorks (now Sedgwick MCO)
12.2001 - 06.2002
Customer Reference Program Specialist
Sterling Commerce
01.2000 - 01.2001
Property & Casualty Agent
American Family Insurance Co
01.1999 - 01.2000
Property & Casualty Agent
Prudential Financial Insurance Company
01.1998 - 01.1999
No Degree - Prep Courses For Dental Hygiene
Lima Technical College
Elementary Education and General Coursework - Prep Courses For Elementary Education
Bowling Green State University
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