TERI WORTHY
DOVER,DE
Summary
As a seasoned quality assurance claims examiner, I have worked for both the Department of Labor and the Social Security Administration, specializing in quality assurance reviews, appeals, and the formal adjudication of disability, workers' compensation, and wage loss claims. I am seeking a role that will allow me to utilize my analytical and critical thinking skills while also providing professional growth opportunities.
Overview
19
19
years of professional experience
1
1
Certification
Work History
Quality Assurance Claims Examiner
Department of Labor
11.2023 - Current
- Evaluated claims processing accuracy, efficiency, and effectiveness, and made recommendations for improvements.
- Identified and evaluated work product flaws. Conducted audits. Offered constructive criticism and recommendations—enhanced staff at lower levels.
- Provided training for office staff, updated policies, reviewed claims for quality, and made decisions on appellate-level appeals and remands.
- Resolved complex compensation claims, approved and lower-level adjudicatory decisions, and processed wage loss benefit reductions and terminations.
- Conducted conferences to resolve contested claims and overpayment issues, negotiated with external parties, narrowed disputes, approved settlements, and prepared a memorandum of decision for the official case record.
- Reviewed and analyzed opioid prescription claims, verified coverage and medical necessity, processed PBM medication approvals, and reported potential fraud or abuse to internal and external agencies.
- Successfully managed a caseload of 425 reconsideration and appeal claims, ensuring prompt and efficient resolutions while proactively addressing all additional responsibilities.
Management & Program Analyst
Department of Labor Office of Workers’ Compensation
10.2022 - 01.2023
- Led cross-functional collaboration to improve ECOMP and iFECS systems, reducing processing errors by 30% within six months.
- Streamlined product backlog and feature testing, improving response times to development inquiries by 25%.
- Served as assistant business product owner and management analyst within OWCP IT department, defining and prioritizing product features, and aligning product roadmap with business goals.
- Collaborated with supervisors from DFELHWC leadership group to explain technological implications of IT system changes.
- Managed product backlog, organized and tested new features, and responded to inquiries from the development team.
- Promoted user-centric design and resolved issues during UAT.
- Prepared test data, test case scenarios, and logs, monitored issues and tickets through Jira.
Sr. Workers’ Compensation Claims Examiner
Department of Labor-OWCP
07.2020 - 10.2022
- Adjudicated and authorized wage loss and medical benefits for disability and death claims under the Federal Employees' Compensation Act.
- Identified potential rehabilitation candidates and collaborated with a specialist to ensure the claimant's successful return to employment.
- Identified potential rehabilitation candidates and worked with a specialist to ensure the claimant's successful return to employment.
- Reviewed and responded to congressional inquiries and other sensitive and urgent administrative actions.
- Arranged second opinion examination, gathered evidence about the permanent nature of their impairment, reviewed and evaluated all medical reports, records, and statements, including the claimant's statements and third-party allegations to determine the factual components of the claim.
- Made determinations in cases involving controversial medical and factual issues, determined compensation pay rates, authorized payments, secured medical documentation, reviewed earnings, made adjustments, and prevented false claims in cases involving dual benefits.
- Established and maintained relationships with external government-affiliated organizations like OPTUM, PBM, CSNI, and vocational rehabilitation, ensuring effective communication
- Conducted extensive research on the Employee Compensation Appeals Board's rulings and findings, ensuring informed decision-making in complex cases involving injury and disease claims.
- Submitted medical evidence to the District Medical Advisors (DMA) to assess the medical necessity of requested medical procedures, durable medical equipment (DME), arthroplasty, and spinal surgeries.
Benefit Authorizer / Legal Administrative Specialist
Social Security Administration
04.2015 - 07.2020
- Finalized entitlement to Social Security Benefits. Maintained the SSA Master Beneficiary Record and other systems data. Analyzed and resolved complex alerts and exceptions. Made final determinations on post-entitlement issues and provided occasional coverage for the SSA National 800 number.
- Responded to information requests from field offices and beneficiaries. Updated beneficiary records. Drafted letters detailing beneficiaries' eligibility for benefits. Verified eligibility and ensured policy compliance.
- Ensured seamless benefit authorization, maintained accurate records of benefit authorizations and claims, collaborated with departments for efficient claim processing, provided exceptional customer service throughout benefit authorization process.
Customer Service Representative/ Tax Examiner
Internal Revenue Service, IRS
11.2012 - 04.2015
- Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
- Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
- Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
- Responded to customer requests regarding tax matters. Explained tax law and researched submitted paperwork.
- Reviewed 1040E, 1040A, and 1040X for errors. Processed amended tax returns. Corrected taxpayer mistakes and adjusted accounts.
Customer Service Representative
Prudential Financial
11.2011 - 11.2012
- Responded to customer requests for information on investments, product services and programs, and products. Enhanced customer satisfaction by promptly addressing concerns and providing accurate information.
- Developed strong product knowledge to provide informed recommendations based on individual customer needs.
- Developed rapport with customers through active listening skills, leading to higher retention rates and positive feedback from clients.
- Processed reallocations and trades via Prudential's Investment Service Online.
Adminstrative Assistant II
Citizens Bank
11.2010 - 11.2011
- Contributed to a positive work environment with strong interpersonal skills and a proactive teamwork attitude.
- Greeted guests with friendliness and professionalism.
- Answered incoming phone calls to process requests, transfer calls, or relay messages to appropriate personnel.
- Worked closely with management to provide effective assistance for specific aspects of business operations.
- Processed legal bills, completed migration and WebFocus reports, expense and reimbursement reports, verified officer and DDA changes in Shaw, ordered documents and supplies, and planned work parties and corporate meetings.
Senior Bank Operations Admin.
Citizens Bank
11.2009 - 09.2010
- Worked effectively in fast-paced environments, to complete a case load of 150 case per week.
- Worked with assigned banks and tellers to locate shortages and overages, by reviewing back transactions and teller tape.
- Skilled at working independently and collaboratively in a team environment to balance bank transactions and generated weekly reports.
- Corrected encoding errors, handled daily customer communication professionally, performed clerical tasks like deposit processing, ensured check accuracy, planned and implemented efficient data flow processes.
Senior Compensation Analyst
Citizens Bank
12.2006 - 07.2009
- Improved payroll accuracy with thorough audits and timely resolution of discrepancies.
- Collaborated with cross-functional teams to design and implement merit increase processes that aligned with company objectives.
- Enhanced employee satisfaction by conducting a comprehensive analysis to ensure proper incentives are credited.
- Evaluated financial documents and statements, conducted weekly branch audits.
- Researched fraudulent account transactions for incentive credit, adjusted incentive credit claims, and ensured their approval.
- Monitored the "Bank at Work" database. Provided information and assistance to clients and legal representatives.
Education
B.S. - Business Administration
Chestnut Hill College
Philadelphia, PA05.2010
Skills
- Detail Oriented
- Technologically Adept
- Critical Thinking
- Time Management
- Insurance Knowledge
- Claims Processing
- Analytical Skills
- Quality Assurance Compliance
- Appeals and Grievances
- Data Analysis
- Organizational Skills
- Skilled Decision Writer
Certification
- Real Estate License: May 2005
- Sanford Brown Institute Certified Medical Assistant: June 2004
Timeline
Quality Assurance Claims Examiner
Department of Labor
11.2023 - Current
Management & Program Analyst
Department of Labor Office of Workers’ Compensation
10.2022 - 01.2023
Sr. Workers’ Compensation Claims Examiner
Department of Labor-OWCP
07.2020 - 10.2022
Benefit Authorizer / Legal Administrative Specialist
Social Security Administration
04.2015 - 07.2020
Customer Service Representative/ Tax Examiner
Internal Revenue Service, IRS
11.2012 - 04.2015
Customer Service Representative
Prudential Financial
11.2011 - 11.2012
Adminstrative Assistant II
Citizens Bank
11.2010 - 11.2011
Senior Bank Operations Admin.
Citizens Bank
11.2009 - 09.2010
Senior Compensation Analyst
Citizens Bank
12.2006 - 07.2009
B.S. - Business Administration
Chestnut Hill College
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