Amber Garcia

• Process and finalize Medicare, Commercial, and Self-Funded appeals and grievances, ensuring compliance with regulatory guidelines and timely resolution.
• Maintain accurate records in CRM systems, documenting all interactions with members, providers, and other stakeholders.
• Facilitate timely processing of Medicare appeals adhering to CMS deadlines and regulatory requirements.
• Collaborate with case managers, medical professionals, and legal teams to ensure accurate and fair resolutions.
• Submit both verbal and written notifications to members and providers regarding appeal decisions and resolutions.
• Conduct audits and provide actionable feedback for continuous process improvement.
• Developed and managed documentation for training purposes.

• Facilitated Workers’ Compensation Independent Medical Review (IMR) appeals.
• Coordinated expedited requests, collaborating with the expedited team and Expert Reviewers to ensure timely processing.
• Processed and followed up on insufficient information requests, ensuring all necessary documentation was received.
• Managed Panel Scheduling, including assigning cases to Expert Reviewers, resolving information requests, and providing onboarding training.
• Performed call center and mail duties as required.
• Subject Matter Expert in Preliminary Review and Document Review providing support as needed.
• Created, maintained, and updated training documentation in accordance with document control process.
• Conducted training sessions and audits for new or recently transferred employees.

· Managed workers' compensation claims, assessing medical, indemnity, and legal exposures.

· Conducted investigations by interviewing claimants, medical professionals, and witnesses to determine claim validity.

· Coordinated care by evaluated medical records and treatment plans.

· Set reserves, calculated lost wages, and determined disability benefits in compliance with state laws.

· Negotiated settlements and facilitated early return-to-work.

· Communicated claims decisions and updates to claimants, employers, and providers.

• Managed and processed future medical workers' compensation claims.
• Analyze medical records and treatment plans to assess the necessity, appropriateness, and reasonableness of proposed future medical care.
• Conducted settlement negotiations with attorneys, injured workers and lien claimants.

• Monitored vital signs and reported changes to nursing staff, ensuring timely medical interventions when necessary.
• Assisted nurses with essential tasks, streamlining workflow and increasing efficiency in the healthcare setting.
• Enhanced patient satisfaction by providing compassionate and attentive care.

• Workers' Compensation Claims Adjuster
• Claims Coordinator
• Office Support and Legal Technical