MICHELLE T. MEARS
Placerville
Summary
Experienced professional with extensive background in managing and resolving complex claims, leading teams, and maintaining strong relationships with business partners. Skilled in claims analysis, planning and organization, and investigation techniques. Seeking to leverage expertise to excel as a Claims Manager and contribute to a dynamic organization.
Experienced leader with strong background in guiding teams, managing complex projects, and achieving strategic objectives. Excels in developing efficient processes, ensuring high standards, and aligning efforts with organizational goals. Known for collaborative approach and commitment to excellence.
Overview
25
25
years of professional experience
1
1
Certification
Work History
Claims Manager
CompWest Insurance Company
06.2017 - Current
- Manage a team of 9 adjusters as one of five teams in the overall company.
- Build continued relationships with all business partners to include brokers, insureds, injured workers, and medical providers.
- Act as MPN Liaison for all of CompWest to include additions and removal of providers and investigation and vetting.
- Perform additional projects as requested or needed in order to enhance work productivity.
- Provide authorization for denials, reserves, investigation requests, defense attorney referral, FCM referral based on appropriate analysis of need.
- Review files to make sure they are moving the correct direction and provide any instruction or recommendations to help the adjusters move the claims to resolution.
- Attend in person claim reviews when requested or virtual to moderate and answer any questions if the adjusters are not able to.
- Maintain team atmosphere and work with HR for any issues.
- Hold weekly meetings with the team to keep them updated on any changes going on in the company.
- Attend and conduct trainings to keep in compliance with mandatory training hours.
Senior Resolution Manager
Gallagher Bassett Insurance Services
01.2016 - 06.2017
- Manage various caseloads depending on assignment.
- Work as part of the Transition Service Team working on assignments for temporary vacancy openings, leaves of absence, terminations, etc.
- Set medical and indemnity reserves in an accurate/approximate manner based on the medical information provided and available.
- Authorize or refer medical treatment as necessary to endure a speedy recovery for the claimant.
- Initiate investigations, submit referral to attorneys, follow up with nurse case managers and initiate any benefits as necessary.
- Provide timely and accurate benefits to those claimants who are so entitled and answer any questions that may arise.
- Work up and negotiate settlement of claims based on all medical information available.
- Participate in file reviews as requested and scheduled.
- Work independently as a remote examiner from a home based office.
- Attend meetings and classes to maintain continued education credits as necessary and appropriate.
Senior Claims Examiner
Church Mutual Insurance
12.2013 - 12.2015
- Manage a caseload of approximately 120 claims at present, ranging in degrees of complexity based on the nature of the injury for churches, private schools and senior living communities. Ensuring all medical and correspondence is up to date and active treatment is being sought.
- Provide timely and exceptional customer service to all parties involved on a claim, such as the injured worker, the employer, the doctor and/or any attorney’s involved on the claim.
- Set medical and indemnity reserves in an accurate/approximate manner based on the medical information provided and available.
- Authorize or refer medical treatment as necessary to endure a speedy recovery for the claimant.
- Initiate investigations, submit referral to attorneys, follow up with nurse case managers and initiate any benefits as necessary.
- Provide timely and accurate benefits to those claimants who are so entitled and answer any questions that may arise.
- Work up and negotiate settlement of claims based on all medical information available.
- Participate in file reviews as requested and scheduled.
- Work independently as a remote examiner from a home based office.
- Attend meetings and classes to maintain continued education credits as necessary and appropriate.
- Worked as Lead Examiner in the absence of the Supervisor as well and worked on special projects. Example: Provided write up and completion of training manual for workers compensation assistants as new hires as no prior assistants in the company.
Senior Claims Examiner
Intercare Holdings
07.2013 - 12.2013
- Manage a caseload of approximately 150 claims, ranging in degrees of complexity based on the nature of the injury for a public entity client. Ensuring all medical and correspondence is up to date and active treatment is being sought.
- Provide timely and exceptional customer service to all parties involved on a claim, such as the injured worker, the employer, the doctor and/or any attorney’s involved on the claim.
- Set medical, indemnity and expense reserves in an accurate/approximate manner based on the medical information provided and available.
- Authorize or refer medical treatment as necessary to endure a speedy recovery for the claimant.
- Initiate investigations, submit referral to attorneys, follow up with nurse case managers and initiate vocational rehabilitation benefits as necessary.
- Provide timely and accurate benefits to those claimants who are so entitled and answer any questions that may arise.
- Work up and negotiate settlement of claims based on all medical information available.
- Participate in file reviews as requested and scheduled with travel.
- Attend meetings and classes to maintain continued education credits.
- Provide help and support on any special projects and requested and/or needed.
Senior Claims Examiner
Carl Warren & Company
09.2012 - 07.2013
- Manage a caseload of approximately 125-140 claim, ranging in degrees of complexity based on the nature of the injury for various different employers types. Ensuring all medical and correspondence is up to date and active treatment is being sought.
- Provide timely and exceptional customer service to all parties involved on a claim, such as the injured worker, the employer, the doctor and/or any attorney’s involved on the claim.
- Set medical, indemnity and expense reserves in an accurate/approximate manner based on the medical information provided and available.
- Authorize or refer medical treatment as necessary to endure a speedy recovery for the claimant.
- Initiate investigations, submit referral to attorneys, follow up with nurse case managers and initiate vocational rehabilitation benefits as necessary.
- Provide timely and accurate benefits to those claimants who are so entitled and answer any questions that may arise.
- Work up and negotiate settlement of claims based on all medical information available.
- Participate in file reviews as requested and scheduled.
- Work independently as a remote examiner and do all my own clerical, filing, letters, mail and bill preparation.
- Attend meetings and classes to maintain continued education credits.
- Was Lead examiner for the workers compensation in the office and provided training to new adjusters hired.
Senior Claims Examiner
Patriot Risk Services
08.2011 - 09.2012
- Manage a caseload of approximately 125-140 claim, ranging in degrees of complexity based on the nature of the injury for temporary employment agencies and for skilled medical facilities. Ensuring all medical and correspondence is up to date and active treatment is being sought.
- Provide timely and exceptional customer service to all parties involved on a claim, such as the injured worker, the employer, the doctor and/or any attorney’s involved on the claim.
- Set medical, indemnity and expense reserves in an accurate/approximate manner based on the medical information provided and available.
- Authorized or refer medical treatment as necessary to endure a speedy recovery for the claimant.
- Initiate investigations, submit referral to attorneys, follow up with nurse case managers and initiate vocational rehabilitation benefits as necessary.
- Provide timely and accurate benefits to those claimants who are so entitled and answer any questions that may arise.
- Work up and negotiate settlement of claims based on all medical information available.
- Participate in file reviews as requested and scheduled.
- Train new employees on work management, computer system work flow and company policies and procedures to ensure a successful start to their carrier with Patriot. This includes but not limited to traveling to other office locations.
- Attend meetings and classes to maintain continued education credits.
- Provide help and support on any special projects and requested and/or needed.
Senior Claims Examiner
Keenan & Associates
10.2006 - 08.2011
- Manage a caseload of approximately 150 claims, ranging in degrees of complexity based on the nature of the injury for Northern California Community Colleges. Ensuring all medical and correspondence is up to date and active treatment is being sought.
- Provide timely and exceptional customer service to all parties involved on a claim, such as the injured worker, the employer, the doctor and/or any attorney’s involved on the claim.
- Set medical, indemnity and expense reserves in an accurate/approximate manner based on the medical information provided and available.
- Authorized or refer medical treatment as necessary to endure a speedy recovery for the claimant.
- Initiate investigations, submit referral to attorneys, follow up with nurse case managers and initiate vocational rehabilitation benefits as necessary.
- Provide timely and accurate benefits to those claimants who are so entitled and answer any questions that may arise.
- Work up and negotiate settlement of claims based on all medical information available.
- Participate in file reviews as requested and scheduled.
Claims Consultant
Specialty Risk Services
01.2006 - 10.2006
- Manage a caseload of approximately 150 claims, ranging in degrees of complexity based on the nature of the injury for a client in the supermarket industry. Ensuring all medical and correspondence is up to date and active treatment is being sought.
- Provide timely and exceptional customer service to all parties involved on a claim, such as the injured worker, the employer, the doctor and/or any attorney’s involved on the claim.
- Set medical, indemnity and expense reserves in an accurate/approximate manner based on the medical information provided and available.
- Authorized or refer medical treatment as necessary to endure a speedy recovery for the claimant.
- Initiate investigations, submit referral to attorneys, follow up with nurse case managers and initiate vocational rehabilitation benefits as necessary.
- Provide timely and accurate benefits to those claimants who are so entitled and answer any questions that may arise.
- Work up and negotiate settlement of claims based on all medical information available.
- Participate in file reviews as requested and scheduled.
Workers’ Compensation Claims Adjuster - C
State Compensation Insurance Fund
Redding, CA
11.2000 - 12.2005
- Manage a caseload of approximately 150 claims, ranging in degrees of complexity based on the nature of the injury for state agencies and various different employer types. Ensuring all medical and correspondence is up to date and active treatment is being sought.
- Provide timely and exceptional customer service to all parties involved on a claim, such as the injured worker, the employer, the doctor and/or any attorney’s involved on the claim.
- Set medical, indemnity and expense reserves in an accurate/approximate manner based on the medical information provided and available.
- Authorized or refer medical treatment as necessary to endure a speedy recovery for the claimant.
- Initiate investigations, submit referral to attorneys, follow up with nurse case managers and initiate vocational rehabilitation benefits as necessary.
- Provide timely and accurate benefits to those claimants who are so entitled and answer any questions that may arise.
- Work up and negotiate settlement of claims based on all medical information available, as well as attend WCAB hearing as necessary.
- Participate in file reviews as requested and scheduled.
Education
Bachelor of Arts - Business Administration and Human Resource Management
Simpson University
Redding10-1999
Skills
- Claims analysis
- Planning and organization
- Team motivation
- Investigation techniques
- Claims processing
- Claims auditing
Certification
- Certified Self Insured Adjuster, 11/06/04
- Bachelor of Arts Degree – Business Administration and Human Resource Management, 10/99
- Military Service – United States Air Force, 05/92 – 05/96, Honorable Discharge at the rank of E-4 Senior Airman.
- Unit Leader during Technical School Training.
- Leadership Awakening Course, 2008
AWARDS
State Compensation Insurance Fund, Presidents Excellence Award to 25%, 2003, Adjuster of the Quarter – 2nd Quarter, 2004
Timeline
Claims Manager
CompWest Insurance Company
06.2017 - Current
Senior Resolution Manager
Gallagher Bassett Insurance Services
01.2016 - 06.2017
Senior Claims Examiner
Church Mutual Insurance
12.2013 - 12.2015
Senior Claims Examiner
Intercare Holdings
07.2013 - 12.2013
Senior Claims Examiner
Carl Warren & Company
09.2012 - 07.2013
Senior Claims Examiner
Patriot Risk Services
08.2011 - 09.2012
Senior Claims Examiner
Keenan & Associates
10.2006 - 08.2011
Claims Consultant
Specialty Risk Services
01.2006 - 10.2006
Workers’ Compensation Claims Adjuster - C
State Compensation Insurance Fund
11.2000 - 12.2005
Bachelor of Arts - Business Administration and Human Resource Management
Simpson University