Kathi L. Merrell
Vernon,NY
Summary
Experienced with analyzing and processing diverse claims accurately and efficiently. Utilizes strong investigative skills and attention to detail to ensure fair settlements. Track record of maintaining compliance with industry regulations and providing excellent customer service.
Overview
42
42
years of professional experience
Work History
Workers Compensation Claims Specialist II
Amtrust Financial
06.2022 - Current
- Responsible for investing worker's compensation claims cases from open to close and adhering to the claims processes and procedures with respect to payment, reporting, reserving, and auditing necessary for assigned caseload
- Responsible for contacting all parties involved in the claim, gathering and securing all necessary information to effectively evaluate the claim and outlining and recommending an action plan to manage the claim
- Provide excellent communication with policyholders, injured workers, medical providers, brokers and attorneys during the course of the claim
- Maintain concise diaries in a clear manner by documenting all actions taken throughout the course of the claim
- Ensure assigned claims are properly documented, reserved and processed
- Make any recommendations to Claims Manager as needed with respect to reserves and excess authority
- Responsible for initiating settlement negotiations with the claimant, or claimant attorney within authority
Workers Compensation Team Lead
Utica National Insurance Company
01.2017 - 06.2022
- Communicate directly with insured's, claimants, witnesses, attorneys, medical providers and other by telephone and through written correspondence
- Correspond with Home Office and other field adjusters
- Consult and Coordinate with Supervisor on complex and involved technical matters
- Evaluate exposure and set and adjust monetary incurred to reflect most likely outcome within requisite authority level
- New employee orientation and training as well as the ongoing training needs for the entire unit
- Oversee work performed by the claims service representatives, answer technical questions
- Escalate appropriate files to the regional offices for subrogation purposes
- Coordinate all state licenses or certifications for unit
- Coordinate all state licensing training, maintain all state specific guidelines/manuals
- Maintain and monitor claim file diaries that promote timely investigation and file resolution, assist with all coverage issues
- Coordinate and evaluate claim handling for third party cost savings (Genex, Talispoint, One Call Medical, Optum, Vitalpoint)
- Quality review unit claim handling
Enhanced Medical Only Workers Compensation Adjustor
Utica National Insurance Company
01.2010 - 01.2017
- Confirm Coverage and Compensability
- File EDI and State Forms Accordingly
- Make two-hour initial contact with Claimants & Insured's
- Secure Recorded Statements
- Coordinate claimant medical treatment according to state specific guidelines
- Monitor life of claim for Lost Time/Schedule Loss of Use/Impairment Rating
- Assign vendors for: RX, DME, Diagnostic Imaging, Independent Medical Exams, Transportation/Language, Physical Therapy/Occupational Therapy/Chiropractic Modalities, Dental Peer Reviews, Surgical Authorizations/Management
- Monitor for Vendor Cost Containment
- Assign legal counsel for Hearings/Litigation
- Monitor NY E-Case for NYWC claims
- Confirm treatment according to NY MTG's
Commercial Lines Underwriting Technician
Utica National Insurance Company
01.2008 - 01.2010
- Responsible for working within the appropriate level of authority within underwriting guidelines
- Handle mid-risk accounts; coordinate information pertaining to new business, renewals and amendments supporting underwriting
- Complete and summarize and secure information for quotes, requotes, template preparation, and issues for new business and renewal policies
- Prepare all manual Business owners policies for CRN's and DNR's, issue agency endorsement requests, process manual aggregates, rate, code and issue policies accordingly
- Maintain productivity and quality objectives as outlined
- Interact with various internal departments, and agents relating to coverage and policy information
- Serve as a point of contact for underwriters and agents
- Update manuals, special notices such as steps for BOR's, Manual Aggregates, and Manual policies
- Maintain critical competencies such as applying reference materials and resources, detail oriented and demonstrate follow-through
- Provide professional, reliable and prompt service to co-workers, underwriters, and agents as required
Medical Bill Review Unit
Utica National Insurance Company
01.2004 - 01.2008
- Responsible for processing Workers Compensation medical claims, currently process for the state of Texas
- Have past experience in WC for the state of N.Y., Maryland, W
- Virginia, Tennessee, and The District of Columbia
- Responsibilities include but are not limited to the efficient processing of claims in a timely fashion while maintaining the current turn over time required by each state
- This entails maintaining an open line of communication with the adjustors handling each WC file
- Knowledge of Peer Reviews, 15/8 files, and Subrogation files are required
- Medical Terminology, breakdown of CPT codes on HCFA 1500 claims as well as UB92 claims are all required in efficiently handling claims to determine payments or denials
Medical Bill Processing Center
The Hartford Insurance Company
01.2003 - 01.2004
- Responsible for processing Medical Workers Compensation claims mainly for the state of New York
- Process claims with accuracy and proficiency on a daily basis, respectively with a 15 day turn over rate
- Correspond with adjustors in handling claim profiles, maintain an open dialogue with other MBPC processors, to remain current on all policy changes and adjustments that concur on a daily basis
- Proficient and accurate in data entry for claim handling, vendor updates, resubmission of claims, customer correspondence, daily claim retrieval and adjudication of a specific amount claims daily
PT Secretary
Merrell's Collision
01.1990 - 01.2003
- Responsible for maintaining customer claims with efficiency and accuracy at all times
- Customer service-respond to inbound calls and direct them as needed
- Return all outbound calls in regards to customer's insurance needs
- Resolve billing questions and problems in a timely fashion
- Order all insurance inquiries in regards to a customers needs, document conversations, keep customers aware of current status of claims
Homemaker/PT Home Health Aide
01.1990 - 01.2003
- Responsible for efficient care of home-stricken men and women due to mental and or physical disease
- Requires medication distribution, nutrition, wound care, dressing applications, proper documentation and companionship
High Speed Check Processor
Federal Reserve Credit Union
01.1989 - 01.1990
- Responsible for processing area bank checks at a rapid rate, checking for accuracy and authenticity
- A team player is key as this position relies on the accuracy of fellow employees
- Intense verbal and written communications are demonstrated, as is being able to effectively multi-task and manage daily work activities
Assistant Manager
Acorn Enterprises
01.1984 - 01.1989
- Responsible for maintaining co-worker schedules, money-management, supply and demand ordering
- Communications, customer relations are crucial as is being a team player
- Working a variety of shifts as needed, without hesitation
- Ability to focus on current technology and products, and travel to maintain education on current information needed to maintain position
- Team player with a strong focus on demonstrating ability to achieve goals
Medical Claims Processor/Customer Service
Blue Cross/Blue Shield
01.1983 - 01.1984
- Position required accurate claims processing after an in-dept training period for the specifics required for claim processing
- Medical knowledge of insurance claims, quota required, and intense customer service required as well as computer knowledge
Education
B.O.C.E.S. LPN School - CPR/Home Health Aide
B.O.C.E.S.
01.1998
High School Graduate - NJROTC Graduate-Business Major
Notre Dame High School
Utica, New York01.1983
Skills
- Claims
- Claims processing
- Claims investigation
- Verbal communication
Workers Compensation Adjustor License
Licensed In:
Massachusetts
Rhode Island
New Hampshire
Connecticut
Timeline
Workers Compensation Claims Specialist II
Amtrust Financial
06.2022 - Current
Workers Compensation Team Lead
Utica National Insurance Company
01.2017 - 06.2022
Enhanced Medical Only Workers Compensation Adjustor
Utica National Insurance Company
01.2010 - 01.2017
Commercial Lines Underwriting Technician
Utica National Insurance Company
01.2008 - 01.2010
Medical Bill Review Unit
Utica National Insurance Company
01.2004 - 01.2008
Medical Bill Processing Center
The Hartford Insurance Company
01.2003 - 01.2004
PT Secretary
Merrell's Collision
01.1990 - 01.2003
Homemaker/PT Home Health Aide
01.1990 - 01.2003
High Speed Check Processor
Federal Reserve Credit Union
01.1989 - 01.1990
Assistant Manager
Acorn Enterprises
01.1984 - 01.1989
Medical Claims Processor/Customer Service
Blue Cross/Blue Shield
01.1983 - 01.1984
High School Graduate - NJROTC Graduate-Business Major
Notre Dame High School
B.O.C.E.S. LPN School - CPR/Home Health Aide
B.O.C.E.S.
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