ISIS RODRIGUEZ

Energetic and enthusiastic insurance professional motivated to succeed in fast-paced and deadline-driven professional environment. Comprehensive knowledge of claims adjustments with special knowledge of auto appraisals and CCC pathways estimations. Meticulous Claims Investigator effective at collecting and analyzing data used to devise fair and cost-effective settlements.

• 620- Adjuster license
• CPR certified

• Maintain claim files pending, evaluate claim using facts and supporting date on jurisdiction and injury document records as case proceeds
• Update appropriate parties as needed, providing new facts as they become available, and their impact upon the liability analysis and settlement options.
• Verify the nature and extent of injury by obtaining and reviewing appropriate medical records an documentation.
• Recognize and implement alternative means of resolution.
• Implement negotiation strategy case by case.
• Develop litigation plan with defense counsel, tract adherence to plan in order to control legal expenses and assure effective resolution.
• Review and evaluate all incoming bills before payment.
• Review and render determinations on Critical Illness / Accident / Hospital Indemnity claims
• Respond to all inquiries generated relative to Critical Illness / Accident / Hospital Indemnity claims within established service time frame
• Communicates with claimants, employers, and various medical professionals to gather information regarding the application for, payment of, and ongoing management of STD or LTD benefits
• Calculates the liability for each claim applying all appropriate offsets such as social security, workers compensation and third parties
• Continually assesses claim details to determine if claims are going to exceed case management authority guidelines
• Evaluates and refers appropriate claims to risk management resources such as Vocational Rehabilitation, Managed Care, Fraud, Social Security, and Subrogation
• Determines customer eligibility by reviewing contractual language and medical documentation, interprets information and makes decisions based on facts presented
• Executes on all customer performance guarantees Manages both new claims and open claims equally and maintains decision times
• Responds to all telephonic and email inquiries within customer service protocols in a clear, concise and timely manner
• Adheres to standard timeframes for processing mail, tasks and outliers
• Stays abreast of ongoing trainings associated with role and business unit objectives
• Pays all covered claims accurately and timely
• Policy interpretation and exposure recognition
• Coverage determination, liability investigation and analysis including comparative negligence issue
• Take recorded statements , document the file with every aspect to the claim and make 24 hour contact on new losses towards a prompt resolution
• Request property damage appraisal
• Review medical record and bills to make a bodily injury evaluation, validate accuracy of services and negotiate bodily injury claim with attorney or directly with the injured party.
• Complete bodily injury evaluation summary including causation, diagnosis treatment and general damage.
• Identify and forward files to subrogation
• Refer questionable and suspicious claims to SIU
• Reduce loss ratios through fair and prompt processing of claims
• Set reserves authority up to $100K
• Issue payment to either attorney or injured party
• Set mediation and consult claim with counsel
• Attend mediation and or trail with counsel
• Followed up with customers on unresolved issues.
• Makes same day contact with customers based on the needs of the claim. Explains the claims process to all customers
• Explains all applicable coverage benefits to the policyholder
• Confirms facts of loss
• Determines vehicle location and if drivable
• Offers vehicle repair and rental service options to customers. Coordinates auto physical damage estimate through proper method of inspection
• Arranges for release of vehicles that are accruing storage fees
• Investigates and confirms coverage for claims with low complexity coverage issues including claims where coverage is reportedly clear and new business investigations
• Makes determinations including but not limited to whether the policy is in force for the date of loss, the driver is an insured on the policy, the vehicle is a covered auto, any exclusions or endorsements apply to the loss, and what coverages on the policy apply to the loss
• Take recorded statements
• Create Reserve
• Order Police Report
• Review ISO
• Issue payments to appropriate party
• Refer claim to subrogation if applicable
• Refer claim to SIU if applicable
• Make liability determination
• Send out letters appropriate letters ( First contact letter, Total loss evaluation, Total loss paper work, settlement offer)
• Communicate with Lien Holder , Copart and IAA