Dynamic Senior Claims Examiner with extensive experience at MCCA, skilled in executing comprehensive investigations and ensuring adherence to Michigan No-fault Law, eager to take on new challenges.
Hi, I’m
Mary Karabetsos, CFLE
Senior Claims Examiner
Three Rivers,MI
Summary
Overview
16
years of professional experience
Work History
MCCALivonia
Senior Claims Examiner
07.2018 - Current
Job overview
- Conducts thorough investigations by gathering relevant documentation to complete initial audits of claims submitted to MCCA by its member companies.
- Developed training materials for new claims staff and ongoing education.
- Analyzed trends in claim submissions to identify potential risks.
- Maintained detailed records of all activities associated with each case file.
- Review and analyze complex insurance claims for accuracy, validity, and compliance with the member policy terms. Ensure claims are paid in accordance with Michigan's No-Fault Law.
- Reviews and approves requests for reimbursements on complex Michigan PIP claim files from member carriers.
- Maintains detailed and accurate records of claims, review, and decisions.
- Determines reserve amounts to ensure that MCCA has sufficient funds to pay for any claims that arise, while also maintaining financial stability.
- Collaborate with legal counsel to assess any coverage concerns, and to assist with the resolution of disputed claims.
- Provide guidance to member companies with compliance with MCCA claims policies and procedures.
- Stay up to date and informed about Michigan's No-Fault Law.
- It is a key resource and conducts training for member companies regarding the provisions of the Michigan No-Fault Law.
- Assist in training new employees.
- Attends and participates in Claim Committee meetings and roundtable discussions.
State FarmKalamazoo
Large Loss Senior Claims Specialist
12.2009 - 07.2018
Job overview
- Investigated large loss claims.
- Processed payments accurately and efficiently according to established guidelines.
- Maintained detailed records of all claims activities in the database system.
- Analyzed data to identify trends and improve claims processing efficiency.
- Reviewed and verified customer information to ensure accuracy of claims.
- Created reports detailing the status of outstanding claims for management review.
- Resolved customer inquiries in a timely manner, while maintaining high levels of customer service.
- Maintained an up-to-date knowledge of industry standards and best practices related to insurance claims processing.
- Collaborated with other departments to streamline processes and improve overall efficiency.
- Reviewed medical records for accuracy and completeness according to established guidelines.
- Analyzed claim trends and patterns to identify potential fraud or abuse.
- Supported efficient handling of complex claims and followed up on open, denied, or suspended claims to complete required line items.
- Retained strong medical terminology understanding in effort to better comprehend procedures.
- Coordinated and planned investigations of claims to confirm compensability and coverage.
Education
Western Michigan University
Masters of Arts from Family Life Education
12.2002
University Overview
GPA: 4.0
Western Michigan University
Bachelor of Science from Sociology
04.2001
University Overview
GPA: 4.0
Skills
- Microsoft Office Suite
- Google Workspaces
- Microsoft Teams
- Zoom
- Google Meet
- Gmail
- Yahoo
- Outlook
- Adobe Creative Suite
- Customer service
- Active listening
- Positive attitude
- Problem solving
- Analytical skills
- Critical thinking
- Relationship building
- Legal collaboration
- Reserve determination
- Effective communication
- Coverage evaluation
- Investigative skills
- Interpersonal communication
- Adaptability and flexibility
- Organizational skills
Work Email
Work Email
Mkarabetsos@micatastrophic.comPersonal Email
Personal Email
mc3272@yahoo.comTimeline
Senior Claims Examiner
MCCA
07.2018 - Current
Large Loss Senior Claims Specialist
State Farm
12.2009 - 07.2018
Western Michigan University
Masters of Arts from Family Life Education
Western Michigan University
Bachelor of Science from Sociology