Shannon Powell
Fairlawn,OH
Summary
Expert in managing high-stakes workers' compensation claims with a focus on compliance and quality assurance. Extensive knowledge of statutory requirements and ability to develop strategies that minimize litigation risks while ensuring timely benefit payments. Strong interpersonal skills foster effective communication with claimants, attorneys, and medical providers.
Overview
22
22
years of professional experience
Work History
Workers Compensation Examiner
U. S. Department of Labor-OWCP-DEEOIC
06.2016 - Current
- Investigates, evaluates, negotiates, and settles assigned high exposure, complex claims such as asbestos, other toxic substances, pneumoconiosis, silicosis, cancer, tort cases, and other occupational diseases, following sound claims handling techniques and in accordance with company claims philosophy, statutory requirements, and quality assurance standards.
- Successfully managed tasks autonomously to meet objectives without direct supervision.
- Investigates assigned claims for coverage, promptly notifying any issues, so that position can be evaluated, and appropriate correspondence issued.
- Documented each claim with a comprehensive coverage analysis to enhance claim evaluation and decision-making.
- Recognizes and acts upon opportunities when a Face-to-Face visit would provide maximum value to investigate, establish rapport or minimize litigation potential.
- Oversee the medical aspects of more complex files (to include catastrophic claims or claims with high severity) to ensure quality care in a cost-effective manner.
- Collaborated with network providers, referred to Utilization Management, and engaged Nurse Case Management to secure special opinions from specialists, independent medical evaluations, second opinions, functional capacity evaluations, and medical director input.
- Documents files with all relevant facts and actions taken, action plan, necessary reports, investigative notes, and other data as may be required by the State Workers' Compensation Law, Energy Employee Occupational Illness Compensation Act, Black Lung, Federal Longshore and Harbor Workers' Compensation Act, the State Insurance Department, and guidelines.
- Managed disability through the Return-to-Work Program by securing job descriptions and educating employers on benefits of light duty assignments.
- Ensures accuracy of disability payments by securing wage statements and correctly calculating rates, which may include securing and analyzing tax information.
- Ensures benefit payments are timely and in accordance with statutory requirements so that there is no exposure to penalties or interest.
- Established and maintained adequate claim reserves to ensure fulfillment of ultimate liability, adapting to changing claim circumstances.
- This requires timely responsiveness to changing claim circumstances, with avoidance of stair-stepping or significant adverse development.
- File documentation should be sufficient to explain the rationale for reserve changes.
- Secure approval for any reserves beyond stated authority.
- Completes Serious Claim Notices according to guidelines.
- Obtains medical disability ratings in accordance with statutory requirements.
- Evaluates a reasonable settlement range for claim resolution and negotiates settlements (either directly with the Injured Worker or, if represented, with their attorney) within approved authority levels.
- Execute decision making to analyze claims exposure and litigation, plan the proper course of action, and appropriately resolve claims.
- Recognizes appropriate opportunities for structured settlements and employs the necessary resources to develop and negotiate this type of settlement.
- Directs attorneys in preparing assigned claims for defense and manages legal throughout claim to final resolution/settlement.
- Collaborates with counsel to determine legal plan of action, which may include depositions, medical examinations, and vocational evaluations.
- Ensures litigation guidelines are followed throughout the process and in review/approval of legal bills submitted.
- Recognizes claims with Medicare exposure and works with defense counsel to protect Medicare's interests.
- Obtain Medicare Set-Aside Trusts from approved vendors and send claims to Centers for Medicare Services for approval, when appropriate.
- Monitored and tracked changes in Medicare regulations to ensure compliance.
- Provides requested updates to management on high profile or high dollar claims.
- Prepare and present claims for plan of action and account reviews as requested.
- Provides appropriate level of service to both internal and external customers, communicating claim status to producers, claimants, and employers as requested.
- Assist employers and agents with questions or training needs as requested.
- Execute and ensure best practices for strategies, products, and services.
Workers Compensation Examiner
U. S. Department of Labor-OWCP-FECA
10.2014 - 06.2016
- Adhered to technical guidelines that are promulgated by the Federal Employees Compensation Act, as amended 9/7/74, and expanded by the Regulations and the Procedure Manual, ECAB Decisions, Bulletins, Circulars, and Memoranda from National Office, Regional Office, and the District Office.
- Adjudicated occupational diseases, traumatic injuries, stress, sexual assault, asbestos, TB, and war hazard claims in a timely manner based on quality guidelines that are established by National Office and modified at the Regional and District levels.
- Exercised a moderate amount of judgement on daily basis to interpret policies.
- Facilitated daily communication with claimants, employing agencies, and support agencies to clarify processes and resolve issues effectively.
- Reviewed primary and secondary cases for daily roll payments and periodic roll cases, ensuring timely processing and compliance with established guidelines.
- Issued and crafted final decisions that affirm the case.
- Prepared Statements of accepted facts and refers cases to the Office Medical Advisor/District Medical Director for advice and recommendations regarding causally or the need to obtain complete medical data and resolve conflicts in medical opinion.
- Determined necessary documentation to perfect claims in accordance with current legislation, regulations, and policies, enhancing claim accuracy and processing efficiency.
- Advised involved parties such as claimants, employing agencies, and attorneys about required medical and non-medical evidence for case adjudication.
- Made decisions of eligibility and entitlement for continuation of pay, compensation for wage loss, and medical benefits.
- Ensured complete and timely action on the adjudication of these questions.
- Approved request for surgery and changes of treating physicians.
- Prepared Memoranda to the Directors, Compensation Orders, and Schedule Awards (Permanent Partial Disability awards).
- Monitored cases where liability for injury fails upon a party other than the United States to ensure that the office receives the proper recovery from any settlement made by the third party.
- Reviewed cases for possible overpayment and made recommendations and some development for higher adjudication.
- Applied laws, regulations, policies, and guidance to provide access to agency records while ensuring protected information is appropriately disclosed or withheld.
- Enacted provisions of the settlement agreements, Administrative Law Judges' decisions, Board orders and Court decrees.
- Ensured corrective actions and timing of key remedial factors; exercising judgment to arrive at reasoned recommendations in situations where the Board and Courts leave it to the compliance stage for proceedings to determine the scope and nature of remedial action; and making appropriate recommendations in circumstances where respondent may be relieved of their obligations to comply with Board orders.
- Provided interpretation for different program processes and methods, conducts analysis of the case history to formulate the precise action(s) for respondent(s) following the issuance of order/settlement agreement.
- Oversaw negotiations to secure compliance with the Board order, court decree or settlement agreement, as well as, using seasoned judgment, encouraging the use of mediation or settlement discussions in both informal and formal case processing as a means of assuring that every reasonable effort is made to reach a resolution.
- Utilized an electronic case management system; databases to assist in the analysis of backpay records; and spreadsheet software to calculate backpay and interest.
- Responded to written and telephonic inquiries from program participants, congressional personnel, National Office staff, and other authorized interested parties.
Human Resources Representative
U.S. Department of Veterans Affairs
12.2012 - 10.2014
- Knowledge, ability, and experience in interpreting the regulations and policies utilizing Title 5 CFR, VA Handbook 5005 and 5007.
- Knowledge of special hiring authorities and VA regulations.
- Trained in using OPM's Guide to Processing Personnel Actions.
- Utilize the 5 CFR to find applicable laws and regulations when bringing on board applicants for recruitment and staffing purposes.
- Utilize the VA Handbook daily to research rules and regulations related to HR Recruitment and Staffing when preparing and posting DEU and MPA job announcements to the USA Jobs website by using reference material to ensure proper content requirements.
- Review applicants' qualifications and verify eligible and ineligible applicants for the vacancy announcements.
- Reviewed veterans' preference criteria to ensure compliance with hiring regulations.
- Assist with the training and development of new employees.
- Provided comprehensive human resources management advisory and technical support services for Title 5 and Title 38 employees, including reviewing, coding, and processing personnel actions, preparing offer letter packages, and maintaining personnel subject matter files.
- Setting goals and priorities for my workload and coordinating activities and timelines with other co-workers to ensure that project goals and deadlines are met.
- Drafting and posting merit and delegated examining unit vacancy announcements.
- Advising on the development of credit plans.
- Developing rating and ranking factors.
- Evaluating and making recommendations regarding personnel related actions.
- Answered routine inquiries regarding application procedures and provided HR support to applicants.
- Notifying applicants of the disposition of their applications and forwarding correspondence to disqualified and non-selected applicants.
- Researched and resolved complex human resources issues by leveraging multiple databases to obtain and analyze information, ensuring compliance with regulations.
- Performing work in support of Human Resource action processing function that includes tracking technical coding actions for new and transfer employees.
- Performing administrative support in verifying security level such as NACI, BI and MBI in coordination with the security department to determine personnel actions.
- Troubleshooting personnel action rejects from an automated information system, determines where errors exist and takes appropriate action to ensure accuracy of the database.
- Supported placement and recruitment functions by preparing new and recurring vacancy announcements.
- Conducted new employee orientation sessions via Live Meeting, clearly explaining health and life insurance options, pay systems, leave policies, military deposits, and retirement benefits.
- Preparing accession packages and initial Official Personnel Folders (eOPF) for new hires, checking SF-52s for adequacy of terms, codes, remarks, and inclusion of supporting documents.
- Analyzing documents and determining their impact.
- Gathering and analyzing information from multiple sources to resolve issues.
- Reconcile conflicting or incomplete information to develop solutions to decide what corrective action to take.
- Extensive experience in preparing, maintaining, and managing investigative files.
- Assisting in preparing, maintaining, and managing human resources files.
- Experience in researching and interpreting instructions, guidelines, and procedures.
- Researching information to prepare reports, charts, documents, and announcements.
- Creating and developing presentation materials.
- Preparing summary reports based on research findings.
- Analyzing complex problems and applying sound judgment in assessing the practical implications of alternative solutions.
- Leveraged extensive knowledge of USA Staffing, WebHR, PAID, eQip, and USAJobs to streamline HR processes.
Claims Assistant
U.S. Department of Veterans Affairs
03.2010 - 10.2014
- Provided advisory and technical assistance to eligible veterans, their beneficiaries, professionals, and administrative personnel in private, state, and general health care institutions regarding entitlement and guidelines for the authorization of treatment at the expense of the VA via telephone and in written correspondence.
- Researched, interpreted, obtained, and explained complex information on changes in laws, regulations, policies, rules, or directives, which change entitlements for health care benefits.
- Determined legal eligibility for benefits, preparing authorization letters to facilitate access to care.
- Point of contact for the State Veteran home and verify eligibility of new residents.
- Prepared monthly fiscal obligations for payment from the state home per diem.
- Processed per diem payments through agency database, ensuring timely and accurate financial transactions.
- Received and processed claims for unauthorized medical care and reviews for accuracy.
- Prepared unauthorized claim files and made recommendations for approval.
- Received and processed claims for authorized medical care by using automated medical records systems such as Vista/CPRS.
- Managed the Electronic Data Interchange (EDI) claims as they were submitted through the Health Administration Center (HAC) website.
- Ensured compliance with the Prompt Payment Act.
- Established and reviewed patient records to determine legal eligibility for benefits.
- Reviewed health form documents for completeness and accuracy.
- Reviewed and analyzed patient records to determine appropriate actions.
- Accessed database systems to retrieve and input information.
- Reviewed contract discrepancies and issues based on the VA Healthcare program.
- Reviewed contract obligations based on the payment for state home per diem.
- Retrieved contract over-payments based on the state home per diem.
- Credited contract payments based on the state home per diem.
- Flagged vendors, physicians, medical facilities, and other medical providers.
- Worked with subsidiary systems (i.e. travel, accounts payable and accounts receivable).
- Analyzed and interpreted financial data.
- Extensive experience in preparing, maintaining, and managing investigative files or medical files.
- Experience in researching and interpreting instructions, guidelines, and procedures according to the Veterans Health Administration policies and procedures.
- Provided advice and assistance to customers without supervision.
- Applied rules and regulations to difficult situations without supervision.
Senior Claims Specialist/Processor
Allstate Insurance Company
09.2004 - 12.2008
- Processed auto, boat, RV, property, PIP, and liability claims in a fast-paced environment.
- Independently researched, interpreted, and analyzed claims based on investigations and extremely sensitive claim documents, interviewed claimants and witnesses, reviewed attorney case notes dealing with most aspects of coverage, liability, and damages.
- Investigated auto claims to determine coverage, liability, and damages, ensuring thorough assessment of all relevant factors.
- Conducted investigations to identify subrogation opportunities and detect fraudulent claims, contributing to claim integrity and cost recovery.
- Used the electronic system to process claims through verification of liability and damages to make adjudicative decisions and determination of the appropriate level of adjudicative review and payment.
- Investigated and confirmed facts of loss for automobile accidents.
- Determined coverage, liability, damages, and negotiated claims within authority.
- Provided continuous assistance to the claimant while determining coverage, evaluating liability and damages for final liability claims.
- Managed litigation with defense counsel, provided written recommendations on coverage and final decisions, and tracked issued payments for accountability.
- Determined final liability claims for Auto, Property, Boat, and Recreational Vehicles.
- Trained new employees in security checks, operating guidelines, electronic submissions and overly complex software applications.
- Developed and executed work plans autonomously, ensuring timely completion of tasks without oversight.
- Given complex problems to analyze and apply sound judgment in assessing practical alternative solutions on a claim.
Education
Master's Degree - Justice Administration
Tiffin University
Tiffin, Ohio05-2015
Bachelor's Degree - Criminal Justice
Tiffin University
Tiffin, Ohio08-2010
Skills
- Claims Evaluation
- Claims Analysis
- Claims Processing Software
- Insurance Regulations
- Reserve Calculation
- Managed Care Systems
- Risk Assessment
- Dispute Resolution
- Medical Terminology
- Microsoft Office Suite
- Analytical Thinking
- Problem solving
- Customer service oriented
Timeline
Workers Compensation Examiner
U. S. Department of Labor-OWCP-DEEOIC
06.2016 - Current
Workers Compensation Examiner
U. S. Department of Labor-OWCP-FECA
10.2014 - 06.2016
Human Resources Representative
U.S. Department of Veterans Affairs
12.2012 - 10.2014
Claims Assistant
U.S. Department of Veterans Affairs
03.2010 - 10.2014
Senior Claims Specialist/Processor
Allstate Insurance Company
09.2004 - 12.2008
Master's Degree - Justice Administration
Tiffin University
Bachelor's Degree - Criminal Justice
Tiffin University