Nadirah Donaldson
Trenton
Summary
Dynamic Claims Investigator skilled in managing high-exposure claims and conducting thorough investigations to ensure regulatory compliance. Proven track record in resolving complex cases and mitigating risks while maintaining communication with attorneys, medical providers, and stakeholders. Drives operational efficiency through effective case management and investigative processes.
Overview
15
15
years of professional experience
Work History
Claims Investigator II
NJ Dept. of Treasury Risk Management (Contractor)
07.2025 - 05.2026
- Investigate, handle, defend, resolve, prosecute and settle General Tort Claims including bodily injury, property damage, assault abuse, accidents, slip and falls, malpractice, death, negligence filed against the State of New Jersey under the Tort Claims and Contractual Liability Act, N.J.S.A 59:1-1 et. Seq., aka Title 59.
- Investigation of State Vehicle Liability Claims arising from the operation or use of State owned or leased vehicles, which may include bodily injury or property damage.
- Investigated subrogation claims, filing and prosecuting claims against individuals, companies, and government entities for negligence or intentional acts causing damage to State buildings and infrastructure.
- Managed civil claims and recovery actions against entities causing damage to State properties. Conducted field investigations and interviews to gather evidence and support claims.
- Collaborated with DOL on claims in litigation status to ensure proper handling and resolution.
WC Claims Adjuster III
Genex Mitchell (Volt)
06.2023 - 05.2025
- Investigate and manage complex, litigated and high-exposure claims, conduct thorough investigations by interviewing claimants and witnesses, analyze and review police and medical reports. Determine coverage and liability.
- Managed claims through defense strategy and resolution, set reserves, developed case action plans, identified potential fraud and irregularities, and facilitated negotiations and settlements within established authority levels.
- Coordinate litigation with defense counsel and TPA, develop litigation plans, attend depositions and trial, and negotiate with attorneys and claimants.
- Maintained communication and reporting for caseloads of 150-300 claims, providing comprehensive findings, evaluations, and settlements to policyholders, claimants, attorneys, and stakeholders.
- Coordinate and monitor care with providers, ensure medical management, accuracy in payment calculation and determine compensability.
- Prepare and submit PARS for internal review, maintain claim closing ratio and Diary management in accordance.
- Ensured compliance with state and federal regulations, adhering to client-specific claim handling guidelines and company best practices.
- Remote
Senior Claims Specialist
Corvel (Mindlance)
07.2023 - 04.2024
- Verified workers’ compensation claims by confirming policy coverage and claim acknowledgment.
- Investigated claims to determine validity and compensability, filing documentation with state agencies.
- Established reserves and authorized payments within reserving authority limits.
- Developed action plans with case manager and outcomes manager to minimize claim costs.
- Coordinated early return-to-work efforts with relevant stakeholders.
- Managed subrogation processes and litigation related to claims.
- Reported claims to excess carriers when applicable, ensuring compliance with regulations.
- Maintained professional relationships with customers, providing regular updates on claim status.
Senior Billing / Workers Comp Specialist
14 Street Medical Arts
New York
03.2022 - 03.2023
- Managed peer-to-peer reviews of insurance denials, facilitated appeals, and secured prior authorizations for diagnostic tests including MRI, CT, MRA, and ultrasounds requested by multispecialty providers such as PCP, OBGYN, gastroenterology, neurology, pain management, orthopedics, and cardiology.
- Managed the compilation and submission of clinical documentation and patient encounters for insurance authorization using systems like Athenahealth and eMedNY, ensuring timely processing.
- Reviewed medical claims for potential SIU cases by verifying coding accuracy, cross-referencing clinical records, and collaborating with law enforcement and compliance teams to investigate fraud.
- Analyzed claims data to identify SIU-related aberrant patterns, suspicious billing activities, utilization anomalies, and statistical outliers indicative of potential healthcare fraud, waste, or abuse. Verify insurance and authorize treatment using Athena health, Cover My Meds, FINEOS and NY.gov submit medical claims, monitor payment status, post payments, review and investigate denied claims with New York State regulations, facilitated billing, invoicing, and payment processing for document releases.
- Liaised with insurance companies, healthcare providers, patients, attorneys, SSI, and disability services to coordinate documentation from various sources and ensure compliance.
- Coordinated follow-up care by managing lab, imaging, and testing results.
Supervisor - Invalid Claims Specialist
AmeriHealth (ETeam)
12.2018 - 01.2021
- Led, coached, and mentored a team of 15 claims and audit specialists, fostering a collaborative and efficient work environment.
- Researched and resolved invalid claims by applying claims adjudication procedures with a focus on accuracy and attention to detail.
- Conducted SIU (Special Investigation Unit) investigations involving healthcare fraud, waste, and abuse by subscribers, providers, and employees to protect the integrity of the healthcare system.
- SIU prepared detailed summary reports of findings and collaborated with legal teams, compliance officers, and law enforcement agencies to recover lost funds and support civil or criminal prosecution.
- SIU conducted interviews with claimants, witnesses, and medical providers to confirm if an individual's reported physical limitations align with their actual activities.
- Utilized state fee schedules and addressed MSA QC issues, including billing inquiries, retroactive adjustments, and reimbursement requests. Audited medical bills within statutory timeframes to ensure compliance with medical coding guidelines and departmental policies.
- Developed extensive expertise in claim processing across multiple territories, ensuring adherence to regional regulations and policies.
- Communicated with claims personnel to address issues related to authorizations, pre-certifications, and claim compensability, facilitating smoother operations.
- Tracked, analyzed, and documented claim statuses and resolutions using claims management systems, Trizetto, Facets, AthenaNet, and electronic health records (EHR) platforms.
Supervisor Case Manager III
Horizon NJ Health
West Trenton
05.2011 - 07.2018
- Manage coordination of care, costs and treatment plans for chronic ill members with complex and high-cost conditions.
- Developed comprehensive case management plans to address members' needs and conducted outreach initiatives to connect them with essential resources..
- Oversaw initial assessments, evaluated member needs, and referred complex cases to registered nurses (RNs) for health management.
- Monitored and evaluated effectiveness of care plan and modified plan.
- Provide members with access to appropriate quality and cost-effective care.
- Coordinate with internal and external resources to meet identified needs of the members and collaborate with providers.
- Authorize services per requirements while advocating for members' rights in government programs and navigating grievances and appeals processes for benefits.
- Managed Long Term Care Services & Support (MLTSS) members' hospital and long-term care claims, benefits, and care plans.
- Provide care management services using TriZetto and Facets for healthcare payers, manage claims processing, billing enrollment and provider networks for integration and scalability, member and provider management.
Education
BA - Law & Justice
Rowan University
Glassboro, NJ01-2025
AAS - Criminal Justice
Rowan College Burlington County
Mount Laurel, NJ01-2023
Skills
- Claims Investigation
- Claims auditing
- Regulatory compliance
- Root cause analysis
- Risk Management
- Tort, Medical Malpractice, Auto, Property, EPL, Bodily Injury
- Team Leadership & Staff Mentoring
Timeline
Claims Investigator II
NJ Dept. of Treasury Risk Management (Contractor)
07.2025 - 05.2026
Senior Claims Specialist
Corvel (Mindlance)
07.2023 - 04.2024
WC Claims Adjuster III
Genex Mitchell (Volt)
06.2023 - 05.2025
Senior Billing / Workers Comp Specialist
14 Street Medical Arts
03.2022 - 03.2023
Supervisor - Invalid Claims Specialist
AmeriHealth (ETeam)
12.2018 - 01.2021
Supervisor Case Manager III
Horizon NJ Health
05.2011 - 07.2018
BA - Law & Justice
Rowan University
AAS - Criminal Justice
Rowan College Burlington County