WILFREDO CONTRERAS

• Shoreside Case Manager – Crew Medical Department
• Customer service case manager
• Lead port agents and crew members in different countries
• Instruct port agents with work and follow up instructions
• Quick response to solve issues related to disembarkation process
• Coordinate hotel accommodations
• Coordinate ground transportation
• Book international flight reservations
• Repatriate crew members to their home countries
• Lead crew members while in port how to proceed after being disembarked of the ship
• Review Shoreside Crew Member’s Disembarkation
• Follow up on Emergency disembarkation and Hospital admission
• Relocate crew members in Hotels after hospitalization discharge
• Review with management termination of employment onboard the ship of crew members
• Cause of termination, facts, complaints, master hearing – I-COPE Program review
• Coordinate in port follow up appointments if necessary
• Coordinate Air Ambulance Evacuation in different ports of Landing
• Request hospitalization admission with in network hospitals
• Request Immigration forms from Ship HR and Crew Administrator
• Review Parole letters from Hospital
• Maintain a close communication via email or telephone with crew members while in port
• Request medical records from port agents or assigned network agency
• Request fit to travel from crew members
• Request repatriation flights for crew member’s once they are fit to travel
• Re-locate crew members back to the ship once they are fit for duty with no mayor health complications
• Request Medical and non-medical escorts for onboard Psych cases
• Coordinate travel arrangements to medical and non-medical escorts to assigned landing country
• Review crew member passport with us visa prior to arrival in U.S territory
• Review medical cases with management and medical team on complex medical cases
• Re-assigned cases to repatriated team for continuation of medical care once crew member are fit to travel and Repatriated home
• With continuation of medical care
• Review and reprocess unpaid sick wages
• Travel eligible receipts
• Coordinate follow up appointments with hospitals and ground transportation from Hotel to Medical Facility

Medical Crew – Medical Claims Management

Review medical disembarkation

Review medical diagnosis

Open medical case in share drive folder - medical, diagnosis, invoices expense, correspondence,

Open medical case in Tecnorisk system and add estimated medical expense cash flow

Assist crewmember’s with medical coordination overseas

Assist crewmember’s with medical emergencies if disembarked in foreign countries

Coordinate medical assistance, hospitalization, surgical procedures, inpatient diagnostic referrals

Coordinate immigration parole while in U.S port for medical emergencies

Constant communication with crewmember over the phone and emails

Program disembarkation manifest list for bi-weekly payroll

Coordinate repatriation flights from foreign countries to home country destination

Coordinate Emergency Air Ambulance from country to country due to extreme medical conditions

Review employee contracts and pre-existing conditions and terms

Review vacations and sick time for approval

Prepare and organize excel report for Quarterly KCA

Review by-weekly medical cases and medical clearance with management team

Make sure each case it’s updated with updated medical documentation

Follow up with crewmember’s and corresponding agencies to make sure that crewmembers are receiving medical treatment as instructed

Conducts monthly reviews with the Legal Department and City's TPA on litigated cases and cases that are set for mediation, hearings, settlement, structured settlements and pre-trials

Provides information and guidance to the Law Department regarding litigated claims, mitigating loss trends, reducing frequency loss types, and avoiding losses that could severely

Assists with the development and preparation of the Risk Management Department Policies and Procedures manual
Develops and establishes claims handling procedures
Develops and implements quality control measures
Assigns and supervises the work of claims investigative staff
Establishes reserves on all pending claims

03/2018 – 03/2019

Review FMLA Request Absences

Review Short Term Disabilities Request

Review Long Term Disabilities Request

Review Medical Absences Certification

Process workers Compensations Claims

Review and approve Intermittent Absences Claims

Review or deny Continuous claims

Review newborn baby bonding leaves (Parental newborn care)

Transition claims from FMLA to Short Term Disability

Review FMLA Request for care of Parent of family members (Loco Parental Review apply) Review Adoption and legal documents for time off work (Power of attorneys, Legal representation required)

ICD 10 Diagnosis Review

Interaction with Human Resources – worker’s compensation, FMLA

Review FMLA ACT procedures and guidelines

Exhaust intermittent claim –when appropriate

Review termination of employment and causes with employee and human resources

Review Second Medical Opinion Medical Certification

Reports worker’s compensation claims to insurer and serves as company liaison between insurer and employee

Review and conduct worker’s compensation claims investigation with employee and human resources

Investigates guest and employee personal injury, property, disability, wage, wrongful termination

• Managed large volume of medical claims on daily basis.
• Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.

International Claims Adjudicator – Latin America, Caribbean, Europe, South America
Review Medical Reports
Review Pre-existing conditions for fraudulent claims
Review medical claims expenses and apply UCR (usual and customary reasonable fee)
Respond Emails to Agents in regards to claims status in a timely manner
Negotiate Hospitalization fees for high bills cost
Apply UCR for International Hospital Bills
Apply UCR for Doctors Medical Fees
Review CPT Codes for International Claims
Review ICD 10 Diagnosis for International Claims
Deny claims for exceeding filing time
Review over 90 day claims– lacking medical information
Apply Penalty for non-authorized medical procedures