Jesslyn LaMar

• Tort Claims Trainer for all Point C TPA’s. Create, update, and maintain department specific training materials, policies, and desktop procedures. Appropriate training materials for all Point C TPA’s as requested by Senior Leadership. Train, and mentor new hires for tort claim processing on systems such as the VBA portal, and QicLink software. Analyzed and evaluated medical records t to ascertain the exact medical history for use in the adjudication of personal injury claims. Handle Senior leadership project requests for the creation of training manual directives and documentation, as well as conducting new hire training for all Point C departments and TPA’s (including the claims department). Assist claim examiners with the achievement of good quality. Plan and/or deliver continued education for claims examiners to address new claims processing situations or areas identified as “needs improvement”.

• Investigated, evaluated, and negotiated property claims over the phone or through technology. Determine coverage, loss cost estimates, settlements, and payments according to the company’s policies and regulations. Handled various types of property damages, such as fire, water, mold, or bodily injuries. Communicated with policyholders, claimants, vendors, attorneys, and claim adjusters in regard to negotiations, investigative findings, and /or research results. Adhere to state regulatory requirements and quality standards. Determine degree of liability, monetary value, and comparative fault assessments on received claims. Researched, interpreted, and applied state and federal case law, statutes and regulations to assess personal injury and/or property damage claims filed pursuant to the Federal Tort Claims Act.

Conducted legal research utilizing LEXIS. Analyze transactions and monitor suspicious activities to identify potential fraud cases.
Implemented policies and procedures to minimize the risk of fraud, including training employees on recognizing and reporting suspicious behavior.
Collaborated with Stakeholders: Worked with internal departments and external agencies, such as law enforcement, to coordinate fraud investigations and recovery efforts.
Utilized analytical tools and software to detect patterns of fraudulent behavior and generate reports of findings.

• Handled Contracting/Credentialing for stipulated providers. Evaluate and review front end contract documents for compliance with standards and policy; Assist with all bid openings; Assist with prequalification of contractors; Monitor website to ensure accuracy of contract administration information; Follow contract administration policies and procedures. Worked multiple projects meeting stipulated guidelines.

• Held primary responsibility for tracking ORS inventory in
  addition to aged reports. Answer questions from inpatient SMEs and processors across all global departments. Field phone calls from vendors, as well as emails from management and senior leadership team members. Relay business requirements to global inpatient processors. Manage inpatient aged files and project files. Routinely update inpatient processors on current standard operating procedures (SOPs). Double-checked company SOPs for intake responses to processors via SharePoint, and make recommendations for suitable courses of action. Advised/trained/mentored processors on numerous SharePoint’s to guarantee efficiency and accuracy in processing claims. Analyzed and evaluated medical records sufficient to draft a concise medical chronology for use in the adjudication
  of personal injury claims.