SHELIA HOOD

• Manage high volume first-party claims ranging from minor theft/vandalism,Water losses, Catastrophic events, Condominium, Attorney represented, Public Adjusters and high complexity Large Loss claims exceeding 230k. By effectively prioritizing tasks and maintaining excellent organizational skills.
• Enhanced customer satisfaction with timely communication, empathy, and clear explanations of claim outcomes.
• Obtain Initial Facts of loss, determine if Liability exist and Subrogation Potential.
• Review insurance and claims documents to verify required information and secure any missing data for settlements.
• Identify fraudulent claims through diligent investigation and collaboration with law enforcement agencies when necessary.
• Conduct detailed investigations into suspicious claims, successfully identifying and addressing fraudulent activities.
• Streamlined claims processing procedures, significantly reducing turnaround times and improving client satisfaction.
• Correspond with agents and customers to investigate questionable claims.
• Complete Virtual inspection of loss and contents.
• Maintain accurate records by diligently updating claim files and ensuring all required documentation was submitted in a timely manner.
• Complete Initial estimate for repairs using Xactimate while ensuring proper coverages and depreciation applied.
• Prepare legal correspondence letters in response to Attorney demand alleging Carrier was in violation of the TX Deceptive Trade Practices for managers or legal personnel.
• Evaluate and settle complex insurance claims fairly within strict timeframes. By applying critical thinking, negotiation skills, and detailed knowledge of insurance policies.
• Delivered comprehensive training sessions for new hires on claims handling procedures, policy interpretation basics, negotiation techniques, and other core competencies related to the role of a Claims Specialist.
• Developed and implemented training programs for new claims specialists, boosting team efficiency and knowledge.
• Handle high-pressure situations with professionalism and composure, consistently achieving positive outcomes for both clients and the organization.

• Conducted prompt, thorough and fair investigation by obtaining relevant facts of loss to determine coverage, origin and extent of loss.
• Ensures proper coverage, reserves, file handling of assigned claims.
• Prepared report of findings of investigation
• Maintained current knowledge of industry trends and best practices through continuous professional development opportunities such as training sessions or certifications courses.
• Examined claims forms and other records to determine insurance coverage.
• Answered customer questions regarding deductibles.
• Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
• Analyzed information gathered by investigation and reported findings and recommendations.
• Documented information gathered in field Xactimate, Eagle View and Scope sheet and uploaded data to company database for efficient processing using ECS.
• Clarified coverage of losses to policyholders and provided assistance in itemizing damages and finding alternative living arrangements.
• Maintained claims data in ECS systems.
• Assisted homeowners by coordinating vendor services, emergency repair, cleaning and contractors.
• Evaluated original investigation reports and documents to resolve secondary concerns.
• Negotiated settlement of claims of varying complexity and peril, achieving prompt, fair and equitable settlement of claim in cases of policy liability.
• Adapted quickly to changing claim environments or new company policies, demonstrating flexibility and resilience in a fast-paced industry.
• Developed expertise in specialized areas such as catastrophe response or specific types of property damage to better serve clients'' needs during critical situations.
• Managed multiple priorities simultaneously while ensuring all tasks were completed within set deadlines and quality standards maintained.
• Prepared summaries of damage, payments, and policy coverage.
• Identified suspicious losses and contacted manager for investigative assistance.
• Conduct Virtual inspection of loss, write estimates for repairs
• Investigate and assess damage to property and create or review property damage estimates using Xactimate
• Work with contractors, building consultants during the estimation process to settle and pay claims.
• Demonstrated expertise in investigating, evaluating, and resolving claims promptly and accurately.
• Maintained up-to-date knowledge of industry trends, laws, regulations, and best practices.
• Directed claims negotiations within allowable limit of $25,000 and supported successful litigations for advanced issues.

• Liberty Mutual INSURANCE - Supplement Review
• Reviewed Supplement for settlement
• Reviewed and Reconciled property damage Supplement estimates using Simbility
• Reconciled within required statutory time frame
• Interpreted policy language and evaluated coverage on multiple different policies and endorsements
• Evaluate and set proper reserves
• Conducted Virtual inspections
• Worked with contractors, building consultants to determine warranted repairs
• Created and Negotiated with, contractors, AOB's, public adjusters and/or attorneys based on facts of the loss
• Issued payments based on coverage, field reports, and verifiable damage

• Citizens Insurance – QA Review
• Reviewed Initial inspection Estimates and photos
• Reviewed and evaluated Initial Estimates
• Reviewed, Eagle view, Hover reports
• Reviewed Mitigation Logs, documents
• Interpret policy language and evaluate coverage issues of multiple different policies and endorsements
• Approved and rejected Estimates
• Communicated with Field adjuster when additional information or revision needed
• Forwarded approved Estimates to DA for final review and payment

Progressive Insurance, Security First Florida

• Handled all matters while adjudicating the loss and presenting the claim
• Conducted effective interviews with policyholders, to gather comprehensive information related to a claim''s investigation process.
• Conducted prompt, thorough and fair investigation by obtaining relevant facts to determine coverage, origin and extent of loss.
• Affirmed or denied coverage of claims based on facts and policy terms and conditions, developing information necessary to make advance, partial and final payments when appropriate.
• Evaluate and set proper reserves for claims
• Creates Letters and document claims file to comply with company guidelines and state regulations
• Adapted quickly to changing claim environments.
• Prepared summaries of damage and estimates using Simbility.
• Maintained electronic claim files with accurate, clear and timely information and reports reflecting adjustment activities and substantiating any payments made.
• Ensured regulatory compliance in handling claims by adhering to state laws, insurance policies, and company guidelines.

• Provided support and services in terms of proving medical necessity and appeals filing
• Managed appeals team
• Trained team members to ensure proper knowledge of HMO AUTO PPO POS Medicaid/Medicare and workers compensation procedures
• Critique prescriptions; chart notes: operative reports: discharge summaries: x-ray interpretations and chart note accuracy
• Follow formal written policy on submission of issues to Health Care Compliance for review
• Critique medical documents based on CMS, Federal and Orthofix written guidelines, policies and procedures (Revenue Integrity)
• Endured timely verification and authorization of insurance as required
• Provide timely follow up for pending authorizations and required billing documents
• Determine revenue amounts based on allowable, benefits, payer guidelines, co-payment and booking policy
• Provide client feedback on coding errors or omissions
• Funds Data Integrity, Contract Modification Logs
• Contractor Notification and Follow up to resolve Recycle List Issues
• Resolve difficulties related to payments
• Trained new employees on company policies, procedures and work ethics.
• Delegated tasks to team members according to individual strengths.
• Worked closely with upper management to develop strategies for improving operational efficiency within the department.
• Oversaw the training of new employees on job responsibilities and expectations.
• Resolved conflicts between team members and departments.
• Communicated employee, customer and workplace needs to managers.
• Set performance goals for staff members and helped teams meet important deadlines.
• Organized workflow tasks to prevent downtime and production gaps.
• Coordinated employee schedules according to availability and approved shift changes.
• Increased team productivity by implementing efficient workflows and setting clear expectations for staff members.
• Enhanced communication within the team by holding regular meetings and encouraging open dialogue among all members.
• Demonstrated commitment to the organization''s core values, leading by example and fostering a culture of excellence.
• Collaborated with other departments to achieve organizational goals, fostering teamwork across various functions.
• Mentored junior staff members in their career development, sharing knowledge from years of experience in the field.
• Conducted thorough employee evaluations to identify areas for growth and development, leading to more skilled workforce.

• Provide information and instructions about workers Compensation and FMLA benefits to employers and injured workers and investigate case by case situations determining compensability and benefits.
• Conducted comprehensive interviews of witnesses and claimants to gather facts and information.
• Determined compensability and benefits due. Monitored minor reserves up to $10,000.00 accuracy and filed necessary documentation with state agency
• Negotiated settlement of claims within designated authority
• Calculated and assigned timely and appropriate reserves to claims; managed reserve adequacy throughout the life of the claim
• Documented files to include all key activities, contacts made, statements taken, including a full outline covering all aspects of the claim and requirements for resolution and process claims
• Adjudicated lost time claims in multiple jurisdictions
• Managed medical treatment to provide highest level of care while controlling costs
• Reviewed medical evidence provided by treating physicians to evaluate benefit entitlement determinations.
• Reviewed reports, medical treatment records, and video footage to determine extent of liability.
• Responded promptly to inquiries from claimants or employers concerning specific cases.
• Negotiated settlements between insurers, healthcare providers when appropriate.
• Facilitated dispute resolution between employers and claimants through mediation or arbitration proceedings.
• Ensured claim files are properly documented and claims coding is correct.
• Coordinated return-to-work programs for injured employees when medically feasible.
• Participated in training sessions for new employees regarding the company's workers' compensation policies.
• Developed in-depth knowledge of Workers' Compensation laws and regulations.

• Evaluated unit cost and price data for purchase or sale of goods and services; monitored suspense actions
• Provide information and instructions about retirement, survivors, disability, and Medicare insurance eligibility, conducting timely, high quality interviews, determining problem or interest's nature
• Maintain regular oversight of daily production planning
• Conduct general data integrity of document the need for corrections
• Funds Data Integrity, Modification Logs
• Resolve difficulties related to scheduled deliveries
• Process status requests, providing information as needed
• Interpret laws, rules, regulations, and written guidelines
• Ordered supplies and maintained weekly inventory of perishables
• Maintained fiscal and budgetary documents, price lists, menus, scheduling, and contracts
• Entered, stored, and maintained information (written, electronic)
• Recognized for providing relief assistance during Iraq Freedom regarding training requirements, inventory, and readiness support operations
• Provide general support to Company Commander
• Prepare and process documents in support of relocations
• Collaborated with internal teams to develop best practices for supply chain management.
• Utilized forecasting techniques to anticipate customer needs and reduce inventory levels by 15%.
• Coordinated international shipments, including customs clearance documentation processing.
• Developed and implemented strategies to optimize logistics operations, resulting in a 20% reduction in transportation costs.
• Reviewed invoices for accuracy prior to payment authorization for vendor services rendered.
• Identified areas of improvement within existing supply chain operations procedures.
• Maintained high level of communication with customers regarding shipment status updates.