Jose Saenz Email & Phone Number

Chicago, Illinois

Houston, Texas

Eden Prairie, Mn

Assisted in the creation of several successful courses (both instructor led and self-paced). Facilitated instructor led courses in person and virtually. Served as Subject Matter Expert in relation to the newly developed claim adjudication application. Served as mentor for new hires.Assisted in implementing Kanban methodology. Assisted software developers understand the health care claim process. Served on committee entrusted to create corrective action plan for poor employee survey responses. Collaborated with several departments to create “crosswalk” between applications for new software implementation. Served as Project Manager for software implementation of new clients. Evaluated business specific needs to optimize training needs. Created standardized process for uniformed course preparation and documentation. Prepared reports of training matrices for upper management.

Eden Prairie, Mn

Assisted in the successful takeover of claims from another third-party administrator.Investigated claims and determined jurisdiction & compensability.Adjust claims within: MO, UT, CO, IL, SD, AR, KY, PA. Serve as resource, to less experienced staff.Evaluated exposure and establish appropriate reserves.Calculated benefit rates and ensure timely disbursements.Prepared files for presentation to client.Evaluated and reported status of claim’s to upper-management.Serve as liaison between client and defense attorneys.Evaluate files for settlement potential vs total exposure.Direct legal efforts to ensure most favorable outcomes for the client.Assist unit to remain within client expectations.

Houston, Texas Area

Monitored & Settled Workers’ Compensation claims with jurisdictions in: AK, CA, UT, WY, MT, ND, CO, NM, KS, OK, TX, LA, AR, AL, MS, IL, IN, KY, OH, WV, PA, Jones Act and USL&H . Evaluated exposure and approved reserve levels from third party administrator.Performed and participated in file reviews for evaluation of third party administrator’s staff, resulting in re-education & training.Evaluated and reported status of claim’s to upper-management.Investigated claims to determine proper jurisdiction & identify safety concerns.Assisted Legal Department with discovery, answers and subpoenas, in preparation of (and response to) suits.Assess the value of claims and negotiate settlements.Reviewed files and ensured compliance with proper oversight agency.

Houston, Texas Area

Supervised Workers’ Compensation claims with jurisdictions in: Texas, Louisiana, Oklahoma, New Mexico, Arkansas, Florida, California, and Illinois, for national clients. Reviewed and updated procedures for the branch office.Performed file reviews for evaluation of staff, resulting in re-education & training.Evaluated and reported status of claim’s to clients.Investigated claims and determine jurisdiction & compensability.Evaluated exposure and establish appropriate reserves.Calculated benefit rates and ensure accurate & timely disbursements.Reviewed files and ensure compliance with the Texas Workers’ Compensation Act.Prepared file summaries & status reports for clients.

Houston, Tx

Assisted in the evaluation and implementation of policy and procedure manual. Investigated claims and determine jurisdiction & compensability. Serves as resource, and trainer, to less experienced staff. Evaluated exposure and establish appropriate reserves. Calculated benefit rates and ensure timely disbursements. Prepared files for presentation to client. Reviewed files and ensure compliance with the Texas Workers’ Compensation Act. Prepared file summaries & status reports for client.

Austin, Texas

Advised and assisted in the implementation of a new claim’s system. Created and implemented policy and procedure manual for the claims unit. Reviewed and evaluated all open claim files resulting in a closure rate of over 50%. Released reserves in excess of $2,000,000.00. Evaluated staff, resulting in hiring & terminating of staff. Evaluated and reported status of claim’s unit to Board of Directors. Served as liaisons between TCGT and legal representation. Assisted in the creation and preparation of the annual member safety meeting. Evaluated, and modified approved vendor list. Assisted in changing PBO ranking from a “Poor Performer” to a “High Performer”. Investigated claims and determine jurisdiction & compensability. Evaluated exposure and establish appropriate reserves. Calculated benefit rates and ensure timely disbursements. Prepared files and serve as Legal liaisons. Reviewed files and ensure compliance with the Texas Workers’ Compensation Act. Prepared file summaries & status reports for membership.

Houston, Texas Area

Trend grievances/complaints, to identify possible areas and/or providers for investigation. Investigate allegations of healthcare fraud and (when necessary) report findings to the District Attorney. Investigate allegations of healthcare abuse and (when necessary) report findings to the Texas Department of Insurance. Serve as liaison for regulatory agencies, Federal & State prosecutors. Organize staff training for instruction on reporting suspected healthcare fraud and/or abuse. Investigate claims and determine jurisdiction & compensability. Evaluate exposure and establish appropriate reserves. Calculate benefit rates and ensure timely disbursements. Review files and ensure compliance with the Texas Workers’ Compensation Act. Prepare file summaries & status reports for other departments and clients.

Houston, Texas Area

Investigate claims and determine jurisdiction & compensability. Evaluate exposure and establish appropriate reserves. Calculate benefit rates and ensure timely disbursements. Prepare files and serve as Legal liaisons. Review files and ensure compliance with the Texas Workers’ Compensation Act & US Longshore and Harbor Workers’ Compensation Act. Assess the value of a file and negotiate settlements. Prepare file summaries & status reports for other departments and clients.

Corpus Christi, Texas Area

Investigate claims and determine compensability. Determine exposure and establish reserves. Calculate benefit rates and ensure timely disbursements. Prepare and present files at Benefit Review Conferences.Review files and serve as Legal liaisons at Contested Case Hearings. Monitor claims to ensure compliance with the Texas Workers’ Compensation Act. Prepare file summaries & status reports for clients.

Mcallen, Texas Area

Developed and maintained a process by which grievances and appeals were resolved in accordance with Texas Department of Insurance statutes and regulations. Trended grievances & appeals, to identify problems and barriers with the organization. Organized staff, and membership, orientations for instruction on the Grievance & Appeals process. Communicated with team members, to facilitate physician understanding of contracted process. Served as liaison for regulatory agencies, members, providers, and attorneys. Developed and implemented policies insuring OSHA regulations and standards were adhered to. Contributed to, and assisted in implementation of company safety plan. Oversaw the negotiating process, and settlement, of WellCare Contracts, due to selling of Certus HealthCare, LLC. Researched, and resolved, all provider appeals for rejected claims. Assisted in the coordination, and enrollment, of “large” groups.

Law

Bachelor Of Science - Bs, Political Science And Government