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PIP Adjuster & Litigation Claims Representative Resume Example

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PIP ADJUSTER & LITIGATION CLAIMS REPRESENTATIVE
Summary

"To obtain a Sr. senior position as a Pip insurance adjuster, Pip case manager or claims examiner. My objective is to continue to provide excellent service, I look forward to my career in the insurance industry, to excel with greater responsibilities and duties.

Claims Tier Levels:  


  • PIP Adjuster III PIP/Med Pay
  • SIU Adjuster/Subrogation
  • PIP Demand Adjuster
  • Litigation Adjuster
  • PIP Case Management
  • Work Compensation Specialist
Highlights

Excel/ Clios, Legal Exchange, Corvel, As400, Mitchell Billing

Power Point/ Word 2010/

Word Outlook
Accomplishments

PIP Adjuster III/ PIP Demand Adjuster/Litigation Adjuster and PIP Case Management

Experience
PIP Adjuster & Litigation Claims Representative 05/2011 to 04/2013 State Farm Insurance Tampa, FL
  • Process Medical Payment Coverage (MPC), Personal Injury Protection (PIP), Accident Benefits (AB) Claims and Medical Claims Management: Confirm insured facts, update parties to the loss information.
  • Explain relevant coverage, pay claims within authority granted.
  • Complete treatment calendars/ diary.
  • Send original and pattern dictation and claim representative-dictated letters as requested.
  • Pay adjustment expenses up to granted authority levels.
  • Organize medical records in files, verify treatment dates.
  • Obtain medical records, using a medical authorization, handle the details involved in scheduling Independent Medical Examinations (IMEs) or Utilization Reviews (URs) once management has made a decision one is needed.
  • Communicate Explanation of Reviews (EORs) to medical providers and insured.
  • Review Litigation files and handling case management in the litigation phase, prepare correspondence to Defense attorneys, review pleadings, complaints, discovery responses, motions, and set up depositions, schedule.
Tutoring Coordinator 11/2009 to 04/2011 Education Advantage LLC Ft. Lauderdale, Florida
  • Responsible for supervising after school tutors at various school sites, paring student learning plans, data entry, project management and document submittal.
  • Routinely communicate with corporate office, lead tutors, school administration, company staff and Title 1 office.
  • Maintain highly organized and detailed records per assigned region during the SES season Evaluate and report student progress through various mediums (i.e.
  • SLPs, Progress Reports) Update and maintain on-line systems to include student and tutor attendance, student profile and document database.
  • Attending regular meetings provide service to all students through proper tutor-to-student assignment ratios.
  • Ensure timely and accurate tutor submittal of time sheets, attendance forms,.
PIP Adjuster 01/2004 to 07/2008 Direct General Insurance Tampa , FL
  • Maintain claim files pending, evaluate claim using facts and supporting data on jurisdiction and injury, document records as case proceeds.
  • Update appropriate parties as needed, providing new facts as they become available, and their impact upon the liability analysis and settlement options.
  • Verify the nature and extent of injury by obtaining and reviewing appropriate medical records and documentation.
  • Recognize and implement alternate means of resolution.
  • Implement negotiation strategy case by case.
  • Develop litigation plan with defense counsel, tract adherence to plan in order to control legal expenses and assure effective resolution.
  • Review and evaluate all incoming bills before payment.
Works Comp Specialist 01/2002 to 01/2003 Travelers Insurance Tampa, FL
  • Investigate losses through interviews, recorded statements, data documents gathering and securing evidence.
  • Evaluate liability and submit recommendation on coverage.
  • Identify suspicious claims refer or handle appropriately.
  • Maintain diary, pending and reserves.
  • Review all information provided on a medical bill, including ICD-9® codes, to verify the diagnosis and treatment are consistent with the alleged injury and the facts of the loss.
Sr. Claims Exaimer 01/2000 to 01/2002 Cadent Health Care St. Pete, FL
  • Reviews claim forms then determine type and amount of claims to be paid.
  • Analyze information gathered by investigation and report findings and recommendations.
  • Compare the provisions of the insurance policy and applicable laws with submitted information to determine the validity of the claim.
  • Calculate benefits payable Handles the calculation of the appropriate amount and method of payment of policy proceeds.
  • Communicates with policyholders, beneficiaries, and/or health care providers concerning claim handling, claim denials, claim payments and policy contract provisions.
  • Evaluate medical and/or other necessary information relevant to the claim analysis.
Claim Examiner 01/1997 to 01/1999 Aetna Us Health Care Tampa, FL
  • Reviews and adjudicates health related claims based on policy provisions and established guidelines Requests additional information from members and providers as needed Initiates and completes claim investigations when indicated including pre-existing conditions, accidents, medical necessity and appropriateness, eligibility and coordination of benefits Documents fully claims referred to senior staff for review and determination Maintains company production and quality standards of 95% statistical accuracy and 99% payment accuracy.
Education
Certification: ACA Accredited Claims Adjuster ACA Accredited Claims 2003 Hillsborough Community College Tampa, F, Hillsborough

Division of Continuing Education
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Resume Overview

Companies Worked For:

  • State Farm Insurance
  • Education Advantage LLC
  • Direct General Insurance
  • Travelers Insurance
  • Cadent Health Care
  • Aetna Us Health Care

School Attended

  • Hillsborough Community College

Job Titles Held:

  • PIP Adjuster & Litigation Claims Representative
  • Tutoring Coordinator
  • PIP Adjuster
  • Works Comp Specialist
  • Sr. Claims Exaimer
  • Claim Examiner

Degrees

  • Certification : ACA Accredited Claims Adjuster ACA Accredited Claims 2003

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