Microsoft Office
Tanya Thomas
Insurance Adjuster
D'Iberville,MS
Summary
Analytical Claims Specialist with proven experience investigating and resolving property, health and business claims. Delivers professional and balanced customer service and meets needs of insured, claimant and internal and external customers. Insurance expert with exceptional knowledge of legal liabilities and claims practices and superior interpersonal skills.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Senior Indemnity Claims Specialist
CorVel
Overland Park, KS
06.2022 - Current
- Reviewed and analyzed insurance claims to determine validity, completeness, accuracy, and eligibility for payment.
- Investigated complex or high-value claims to identify discrepancies and fraud indicators.
- Researched medical records to evaluate claim validity and verify the existence of pre-existing conditions.
- Interpreted legal documents related to claims processing such as contracts and policy language.
- Maintained detailed records of all claim activities including notes about conversations with claimants or representatives.
- Analyzed settlement offers against liability limits set by insurers.
- Collaborated with other departments within the organization to resolve issues related to claims processing.
- Communicated with other departments to establish action plans and manage open claims to closure.
- Planned and conducted investigations of claims to confirm coverage and compensability.
- Resolved claims by approving or denying documentation, calculating benefits due and determining compensation settlement.
- Assessed and conducted negotiations within authority limits to settle claims.
- Determined covered insurance losses by studying provisions of policies or certificates.
- Drafted statements of loss to summarize damages, payments and underlying policy coverages.
- Conducted interviews with involved claims parties and witnesses to gather detailed information and arrange investigations.
- Retained strong medical terminology understanding in effort to better comprehend procedures.
Adjuster II
Liberty Mutual
Aubrey, TX
09.2021 - 06.2022
- Investigated insurance claims to determine liability and damages.
- Negotiated settlements with claimants, attorneys and other parties.
- Analyzed policy provisions, legal documents and medical records.
- Drafted correspondence related to claim investigations and settlements.
- Assessed potential losses for insureds in accordance with applicable laws and regulations.
- Evaluated subrogation opportunities to identify recoverable funds.
- Maintained detailed records of all claim activities in a timely manner.
- Provided coverage opinions based on analysis of facts, law, policy language and endorsements.
- Reviewed property damage estimates for accuracy and completeness.
- Established reserves for each claim based on analysis of the facts and applicable law.
- Coordinated activities between multiple departments within the company.
- Participated in training sessions related to new policies or procedures.
- Discovered occurrences of insurance fraud or criminal neglect to avoid workplace liability.
- Conducted witness interviews to assist claim information gathering process.
- Completed required investigations on referred files within established timeframes.
- Identified and collected evidence and determined value to specific claim to properly assess conditions.
- Drafted statement of loss to summarize damages, payments and underlying policy coverage.
- Investigated questionable claims to determine payment authorization.
- Reviewed data to verify validity of claims and determine case management actions.
Workers’ Compensation Claims Adjuster
York Risk Services, A Sedgwick Company
Dallas, TX
02.2019 - 09.2021
- Evaluated eligibility for benefits based on analysis of case facts and application of applicable laws.
- Conducted interviews with claimants, employers, physicians and other healthcare providers to obtain additional information relevant to the claim.
- Recommended appropriate actions based on review findings including denial or approval of benefits payments.
- Maintained accurate files containing all relevant documents pertaining to each claim.
- Investigated workers' compensation claims to determine eligibility and extent of coverage.
- Reviewed medical records, interviewed employers and claimants, analyzed wage loss calculations, and reviewed evidence for accuracy.
- Prepared detailed reports on claim findings including all pertinent information such as injury description, cause of accident, employer responsibility, and liability.
- Processed benefit payments in accordance with applicable laws and regulations.
- Advised employers regarding compliance with state laws governing workers' compensation insurance programs.
- Negotiated settlements between claimants and employers or insurers when appropriate.
- Provided customer service by responding promptly to inquiries from claimants, employers, attorneys and other stakeholders.
- Drafted statement of loss to summarize damages, payments and underlying policy coverage.
- Checked into questionable claims, interviewing agents and claimants to resolve errors and omissions.
Adjuster
Independent Work
Frisco, TX
07.2017 - 02.2019
- Investigated insurance claims to determine liability and damages.
- Analyzed policy provisions, legal documents and medical records.
- Negotiated settlements with claimants, attorneys and other parties.
- Drafted correspondence related to claim investigations and settlements.
- Assessed potential losses for insureds in accordance with applicable laws and regulations.
- Maintained detailed records of all claim activities in a timely manner.
- Provided coverage opinions based on analysis of facts, law, policy language and endorsements.
- Prepared reports detailing the progress of complex claims investigations.
Claims Examiner II
Guardian Life Insurance
Frisco, TX
11.2015 - 05.2017
- Reviewed medical records and documents to determine coverage eligibility of claims for insurance benefits.
- Performed data entry into the computer system to record information regarding claim status.
- Investigated discrepancies in claims and resolved issues with customers via telephone or written correspondence.
- Assessed accuracy of claim payments by comparing submitted bills to benefit allowance guidelines.
- Advised customers on their rights under their health plan policies when necessary.
- Collaborated with internal departments such as Underwriting, Provider Relations, Medical Management, Quality Assurance., as needed.
- Initiated contact with providers to obtain additional information needed for accurate adjudication of claims.
- Paid and processed claims within designated authority level.
- Communicated with personnel and legal counsel on claims involving litigation.
Disability Specialist
Sedgwick CMS
Plano, Texas
01.2014 - 10.2015
- Compiled, reviewed and processed FMLA leave requests to ensure compliance with the Family Medical Leave Act.
- Analyzed employee eligibility for FMLA leave based on company policy and federal regulations.
- Interpreted state and federal laws regarding employee rights under the Family Medical Leave Act.
- Communicated regularly with supervisors, managers, HR personnel and other stakeholders to provide updates on status of employee's FMLA leave request.
- Investigated potential violations of the Family Medical Leave Act by employers or employees.
- Responded promptly to inquiries from claimants concerning their rights under the family medical leave act.
- Drafted letters to inform claimant about their rights or decisions made regarding their claim.
Claims Intake Specialist
Cigna
Plano, Texas
08.2009 - 01.2012
- Reviewed and analyzed incoming claims to ensure accuracy of information, completeness of documentation, and adherence to policy guidelines.
- Compiled customer documents for review by the Claims Adjuster team.
- Acted as a liaison between the customer service department and other departments within the organization.
- Verified claim data correctness in preparation for processing.
- Addressed customer inquiries to provide information and explanations on coverage and terms, expediting claims.
Customer Service Manager
Smith, Jackson and Associate
West Point, MS
05.2001 - 06.2007
- Provided exceptional customer service to ensure customer satisfaction.
- Developed and implemented strategies for providing excellent customer service experience.
- Reviewed customer feedback and complaints to identify areas of improvement in customer service processes.
- Monitored staff performance to ensure adherence to customer service standards.
- Conducted regular training sessions for staff on new products, services, and customer service techniques.
- Created reports on customer feedback, complaints, and suggestions for management review.
- Developed policies and procedures related to customer service operations.
- Evaluated overall effectiveness of existing customer service policies and procedures and recommended changes as necessary.
- Performed quality assurance checks on calls handled by agents in order to maintain high levels of accuracy in responses provided by agents.
- Collaborated with senior management team members in designing strategies that would improve overall quality of services offered by the organization.
- Served as point-of-contact between customers and internal teams regarding escalated issues requiring special attention.
Education
Customer Service Certification
Hinds Community College
Raymond, MS11-2000
Bachelor of Science -
Western Governors University
Salt Lake City, UTSome College (No Degree) -
Mississippi State University
Starkville, MSSkills
- Documentation Review
- Settlement determinations
- Claims Investigation
- Microsoft Office
- Policy Interpretation
- Insurance knowledge
- Coverage Determination
Certification
Adjuster Licenses: MN, WY, MO, MS, OK, TX, KY, RI, CT, NH
Accomplishments
- Ace Awards - Team work
References
References available upon request.
Software
Outlook
Teams
Claims Software
Interests
Hiking
Swimming
Reading
Cooking
Timeline
Senior Indemnity Claims Specialist
CorVel
06.2022 - Current
Adjuster II
Liberty Mutual
09.2021 - 06.2022
Workers’ Compensation Claims Adjuster
York Risk Services, A Sedgwick Company
02.2019 - 09.2021
Adjuster
Independent Work
07.2017 - 02.2019
Claims Examiner II
Guardian Life Insurance
11.2015 - 05.2017
Disability Specialist
Sedgwick CMS
01.2014 - 10.2015
Claims Intake Specialist
Cigna
08.2009 - 01.2012
Customer Service Manager
Smith, Jackson and Associate
05.2001 - 06.2007
Customer Service Certification
Hinds Community College
Bachelor of Science -
Western Governors University
Some College (No Degree) -
Mississippi State University
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