JoAnn M. Candelas

Working on the City of Austin Account (EMS/All other departments) and managing 125 claims on my caseload. Evaluated and processing complex claims, determining compensability of claim, pay benefits such as TIBs, IIBs, LIBs, SIBs, and DIBs. Attend quarterly meeting and utilize nurse case management services on more challenging related claims and and developed solutions collaboratively. Attend BRC/CCH with legal counsel representation at DWC Field Office. Enhanced customer satisfaction by promptly addressing inquiries and providing accurate information on claim status. Provided exceptional customer service by empathetically addressing claimants'' concerns and effectively explaining the claims process to them.

Work on City of Bryan, City of Beaumont, and City of North Richland Hills accounts. Managing case of 100 - 115 claims; Evaluated, determine compensability, and process claims to ensure benefits were paid accurately. Coordinated quarterly meetings with clients to resolve claims discrepancies and enhance processing efficiency. Implemented quality control measures that enhanced accuracy in claims processing outcomes. Researched claims and incident information to deliver solutions and resolve problems.

Work on the Insurate Inc., Darling Ingredients Inc., Hansen & Adkins Auto Transport accounts. Managing 85 – 115 open claims; processing new claims with client’s handling service instruction, determining compensability, and pay variety of benefits such as TIBs, IIBs, SIBs, LIBs, and DIBs and adjust reserves when appropriate. Attend quarterly claim reviews via zoom.

Working on the JBS Texas account as the dedicated adjuster. Managing 125 open indemnity claims; review and investigate new claims to determine status of injury, determine compensability, and develop a plan of action; collaborate with legal counsel on litigation cases (BRC/CCH). Process disability payments for TIBs, IIBs, SIBs, LIBs, and DIBs; monitor case for continuation of benefits when appropriate.

Working on a hospitality account including hotels, golf courses, and real estate. Handled a caseload of 100-150 claims with a litigation rate of 30%. Perform efficiently while actively managing 125 open indemnity claims; review and investigate new claims to determine status of injury, determine compensability, and develop a plan of action; establish strategies with nurse case manager; collaborate with legal counsel on litigation cases (BRC/CCH). Process disability payments for TIBs/IIBs/SIBs/LIBs/DIBs; monitor case for continuation of benefits; termination of benefits when appropriate. Prepare reports on claims and loss statistic; providing updates and strategies; complete quarterly resolution plans. Conduct quarterly claim reviews with all clients; proving claim updated and strategies. Preparing and mailing claim letters for treatment authorizations, state forms, benefits package, denial, etc. Conduct day-to-day administrative task to maintain information on files.

Worked on the TAC account for all Sheriffs. in the state of Texas. Handle a variety of claim types such as IIBs, TIBS, SIBs, LIBs, and DIBs. Investigate and process claims; identify obstacles to ensure highest quality claims outcome; analyze financial impact of injury circumstances. Perform thorough reviews of all documentary evidence including investigative reports. Coordinate case management with physicians and other health care professionals. Document and communicate all claim activity timely and effectively which supports outcome of claim; complete and monitor timely payments and state filings; plan and set reserves accurately in a timely manner; obtain full recorded statement in English or Spanish (Bilingual speaker); comply with carrier reporting requirements to Excess Carrier. Coordinate quarterly file review on or off site with Employers.

Examine and evaluate claims to determine compensability; pay benefits; accordingly, and adjust reserves when appropriate. Verify coverage and policy; authorize changes medical providers, medical management, rehabilitation services for vocational training; and policies and procedures. Secure recorded statements from English/Spanish speaking injured worker. Evaluate injured workers compliance with medical treatment plan; exam and authorize treatment based on medical necessity criteria. Conduct negotiations for settlements of claims with injured workers and attorneys; ensure appropriate preparation and filings of necessary legal documents. Prepare Loss reports on claims and loss statistics and update the employer in quarterly file reviews.

Conduct three-point contacts and investigate the claim for compensability under General Business Account. Administer income benefits and notices. Ensured reserves adequate, manage medical, legal activity, and ensure compliance with customer service request, including special claims handling procedures. Review claim for purpose of investigation, plan of action, evaluation, and resolution. Process claims consistent with client and corporate policies, procedures, and best practice guides, and in accordance with statutory, regulatory, and ethics requirements. Communicate concise action plan for moving the case to conclusion. Complete carrier reporting with threshold requirements.