Carla Parker Queenan

Hired to effectively and timely communicate with employers, employees and medical providers. Investigate lost-time claims to determine coverage and compensability based on guidelines for the jurisdiction. Partner and collaborate with nurse case managers, vendors and panel counsel to manage the administration of benefits and claim resolution.

• Resolve various claims while ensuring compliance with operational procedures, and conduct investigations, including assessing policy coverage, contacting insureds, injured workers, medical providers, and other parties to determine compensability
• Process claims according to eligibility verification, program benefits interpretation, and provider contracts while pursuing all offset opportunities, including apportionment, contribution and subrogation
• Analyze and investigate all claims for potential fraud, monitor all chargeback expenses, match authorizations, reprocess system processing errors, and report any billing inaccuracies ensuring that there will be no duplicate claim payments
• Oversee efficiencies in communicating terms of the policy, claims settlement procedures, appropriate review, payment process, negotiate settlement of claims, and file closing or reassignment within approved limits of authority
• Work closely with the medical and legal departments for process improvement initiatives and proactively pursue claim resolution opportunities, i.e., return to work, structured settlement, and discontinuation of benefits through litigation
• Collaborate with other departments, i.e., Medical Case Manager, to streamline information required for claims resolution while coordinating the appropriate medical treatment and returning injured party to work when appropriate.

• Delivered consistent service quality during the claim life cycle, including prompt voice-to-voice contact, explaining the process, setting expectations, ongoing communication, follow-up, and honoring commitments to achieve optimal outcome on every file
• Evaluated coverage and applied insurance conditions, restrictions, exclusions, and endorsements; checked available benefits, injured party's eligibility, and applicable limits; examined the applicability of deductibles, co-insurance, and coverage restrictions
• Investigated each claim to acquire relevant facts essential to assess coverage, negligence, medical necessity, and causation/damages for various coverage provided by policyholders, medical providers and technical experts
• Established and maintained appropriate claim and expense reserves while utilizing effective documentation to manage file inventory and expense reserves and record claim file operations to expedite claims resolution
• Proactively developed and managed ongoing litigation with staff or panel counsel by regularly following up with Claim counsel and other relevant personnel and tracking and controlling legal expenses to ensure a cost-effective resolution
• Ensured compliance to state and federal laws and regulations, determined additional coverage issues, including jurisdictional issues and consistently delivered excellent customer service, maximizing operational efficiencies and service standards.

• Performed coverage analysis based on policy information, facts, or allegations and investigated loss facts, made liability decisions and issued payments to necessary parties while maintaining communication with Business policyholders and claimants
• Enforced accurate reporting and documentation by taking recorded statements, ordered police reports and/or scene investigations as well as followed up with body shops on repairs and assisted customers with rental needs.