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Claims Examiner Resume Samples
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10+ years of experience
Analyze claims to determine appropriate benefits in accordance with policy provisions. Collaborated with insurance representatives and claimants to substantiate coordination of benefits order. Prepared and maintained accurate documentation to support legal subrogation claims and work compensation intervention files. Adhered fully to all HIPAA compliance guidelines. Used MS Excel to track and monitor claims progress, payment refunds, and file closure.
- Identified and resolved potential billing errors with medical service providers which resulted in cost savings.
- Relied on by management to assist with claims processing for various claim groups administered by Zenith from across the country because of my ability to quickly understand various benefit plans and procedures.
- Tested the effectiveness of claim system conversions to validate the accuracy of claim system data and processing.
- Provided formal correspondence to respond to a complicated regulatory complaint.
- Demonstrated ability to meet service and quality requirements while working from remote locations without direct supervision.
0-5 years of experience
Handled over 175 claims files of personal injury and property damage claims for first and third parties
- Investigated coverage, evaluate, negotiated and settle auto liability claims
- Reviewed files and send them to recovery or SIU
- Trained and mentored 10 new hires
- Received ACE award for customer service
- Received Special Unit Investigation Award
- Highest percentage in referral to the subrogation unit in 2005
0-5 years of experience
- Manage and delegate tasks to team of 8 direct reports.
- Provide problem resolution expertise in matters of errors and reconciliation.
- Developed and implemented a newborn report to automate and streamline the clearances process and significantly reduce enrollment and claims timelines.
- Designed and launched a batch status report resulting in department-wide backlog reduction.
0-5 years of experience
- Assigned reserve values to claims, made claims payments as necessary and settled claims up to designated authority level.
- Ensured claim files are properly documented and claims coding is correct.
- Preserved confidentiality of all claims files, claims reports and claims-related issues.
- Resolved complex and severe exposure claims using high service oriented file handling.
- Maintained professional client relationships; resolved client issues.
0-5 years of experience
Analyze moderate to complex workers’ compensation claims to determine benfits due. Use established analytical and investigative techniques to conduct investigations to properly set reserves for moderate to high exposure claims involving litigation and vocational rehabilitation. Routinely audited files for payment accuracy within policy and state guidelines while ensuring ongoing adjudication of claims within company standards, industry best practices and client specific requirements.
- Thorough and timely investigations to determine liability and loss exposures with excellent attention to details.
- Assisted and delivered on client specific metrics and requirements on an ongoing monthly basis while maintaining high file quality audit scores.
- Assisted and aided management with providing mentoring to new employees to the team.
- Outstanding organizational, oral communication and interpersonal skills to work with client representatives and customers in stressful and crisis management situations.
0-5 years of experience
Edited and wrote procedural documents for claims examiners and transition project
- Examined and resolved issues with health insurance claims
- Reviewed and responded to incoming provider and member correspondence
- As home processor, coordinated work with local and Ohio offices via internet
0-5 years of experience
Processed different types of claims such as: Medical, DME, Home Care, SNF and Surgery
- Knowledge of EPO, HMO, PPO, POS, Medicare and Medicaid
- Consistently exceeded production and quality standards, maintained 99% financial and 98% procedural accuracy
- Ability to work in multiple and special queues such as Optum claims as well as identifying system issues during implementation of HIX processing
- Primary claims examiner during implementation of HIX processing
0-5 years of experience
Speak with clients in a customer service call center environment regarding their various individual life insurance policies and update required information
- Explain benefit coverage, documenting, and investigating claims from beginning to end.
- Receive calls from beneficiaries regarding recent and outstanding death notifications and answer any related questions
- Communicate with clients effectively and professionally
- Offer excellent customer service by providing complete and accurate information to clients in a multi-task, high-pressure environment that requires attention to detail
- Meet and exceed production, attendance, quality and service goals
- Follow proper client and state regulations to ensure compliance with appropriate guidelines
0-5 years of experience
- Performed complex rule based data conversions and worked across different areas within the Healthcare and Insurance domain
- Properly adjudicated claims bases on my knowledge of covered benefits, insurance and provider contracts
- Interpreted and analyzed client data to add, delete, modify data and also find solutions to individual client problems based on moderately complex to complex business rules
- Ensured accurate and timely completion of transactions to meet or exceed client service level agreements
- Identified and resolved both regular and non-routine issues
- Ability to analyze and process transactions, with a strong understanding of Claims
- Applied Healthcare and Insurance domain knowledge, theoretical concepts, etc. to undertake problem solving
0-5 years of experience
- Investigated and adjusted moderately complex third party auto damage claims presented by or against our renters to ensure claim validity, legal liability and settlement value.
- Established and monitored appropriate claim reserves. Evaluated and negotiated settlement of claims within established settlement authority limits.
- Reviewed loss reports, confirmed coverage, explained procedures, issued claim payments and answered inquiries for auto claims.
6-10 years of experience
Established strong rapport with agents and customers
- Successfully handled catastrophe claims and injuries
- Determined liability and processed 1st and 3rd party claims
- Prepared files for litigation
- Handled all claims timely to mitigate damages and cost
6-10 years of experience
- “Cradle to grave†senior level claim processing for multiple large accounts in a variety of industries for both Oregon and Washington. Processing duties included complying with client, [company name] and jurisdictional requirements, appropriate and timely assessment and payment of claim benefits, thorough investigation of claims for compliance, 3rd party liability evaluation and subrogation recovery, and resolution of litigated issues while working one on one with defense attorneys.
- Two time colleague of the month
- 4th Quarter 2014 Values In Action Honoree
- Successful completion of the Industry Advancement Program at the top of my class.
- Current Washington and Oregon Claims Examiner Certification, with prior training in CA processing.
- Company recognition for exception audit scores over 90%
- Founding member of the “Claim Staffing Roundtableâ€
0-5 years of experience
Completed and overseen a variety of professional assignments to manage a caseload of disability claims by reviewing new claims to determine the validity of claims, ascertaining proper filings, identifying the need for further investigations, and following claims through closing or settlement.
- Obtained relevant medical records and statements from the treating physician.
- Monitored on-going medical treatment for progress and refers claimants for independent medical evaluation.
- Ensured file was kept current to reflect all appropriate forms, statements, and reports.
0-5 years of experience
Handled all claims for members and providers in an efficient and professional manner while meeting and exceeding all departmental production standards effectively
- Ability to make claim payment/denial decision in a timely and accurate manner based on members benefits and eligibility
- In-depth knowledge with ICD-9 codes, HCPCS, CPT and revenue codes
- Dedicated units: Non-participating, durable medical equipment, coordination of benefits specializing in standard and non-duplication methods
- Processed [company name], GEOBlue, and Independence Administrators Local and Blue Card hospital and physician claims
- Blue Squared knowledge to obtain other party liability values from other carriers for processing coordination of benefits and MVA claims
0-5 years of experience
Review and process claims/encounters based upon eligibility, benefits, authorizations and contractual agreements between the HMO and providers.
- Responsible for adjudication of Encounter claims with a daily production of approximately 150 claims per day. Duties also include adjudication of fee for service claims and maintaining production standard of professional and hospital claims per day with an error ratio of no greater than 5%.
- Responsible for timely resolution of pended claims according to department’s compliance standards.
- Identify and notify Claims Manager or Claims Lead of system related issues.
- Assist of departments in research of claims, authorization and adjustments, if necessary.
- Thoroughly review potential duplicate claims submission. Provide detail research on Third party liability cases (TPL), financial responsibility claims of another payer that have been mistakenly paid, or claims paid at the incorrect reimbursement rate.
- Perform other tasks delegated by Claims Management and or Claims Lead.
0-5 years of experience
Analyze and process Workers’ Compensation claims by investigating and gathering information to determine the exposure on the claim.
- Negotiate the settlement of claims up to designated authority level and make claim payments.
- Manage claims through a well-developed action plan to bring claim to an appropriate and timely resolution.
- Report claims to the excess carrier, respond to requests of directions in a professional and timely manner.
- Coordinate vendor referrals for additional investigation and/or litigation management.
- Consistently maintain professional client relationships.
0-5 years of experience
- Consistently maintained one of the highest rates of monthly decisions on a team of 10 claims examiners.
- Volunteered for mentoring opportunities including customer service and LTD new hire shadowing.
- Maintained excellent customer service by regularly exceeding time service, referrals, inventory, and training standards.
- Demonstrated superior customer service and claims decision-making as the sole claims examiner over a prominent group of southern California national accounts.
- Investigated and determined outcome of disability claims with sound and impartial judgment.
- Facilitated effective transition of a short-term disability claim to a long-term disability claim.
- Interacted directly with claimants, policyholders, attorneys, and physicians.
- Practiced effective claims management by identifying rehabilitation opportunities and settlement candidates.
0-5 years of experience
Reviewed medical claims, investigated coordination of benefits, and processed claims per coverages
- Analyzed claims to see if medical records are needed and requested necessary records
- Examined incoming medical records and sent appropriate records on to medical review unit
- Processed payment or denial of claim and ensured that necessary correspondence was sent to both member and provider
- Met individual and department standards with regards to both quality and productivity goals
- Entered personal information, claims information, and other data related to the claim
- Promptly processed the members’ claims within the time frame of our contracts
- Preserved confidentiality of all claims files, claims reports and claims-related issues
0-5 years of experience
- Accurately process medical claims in accordance with company policies and procedures
- Review suspended claims daily to ensure all appropriate documentation has been completed prior to processing
- Review audit results weekly, correcting errors in the claims processing system within designated timeframe
- Maintain performance standards for accuracy and production
- Participate in all training sessions as recommended to remain current on all departmental policies and procedures
0-5 years of experience
Reviewed property claims
- Determined settlement and coverage of claims
- Provided customer service
- Managed large caseload
6-10 years of experience
Claims Examiner
- I am currently working a minor property damage claims desk for a national account specializing in Home Improvement retail.
- I investigate each claim through initial contacts, documentation and evidence that is available. If liability is determined, appropriate reserves are set and settlement is issued.
- First party claims are investigated and set to a subrogation department for recovery.
- Product claims are tendered to the manufacturer.
- Installed sales claims are tendered to the subcontractors insurance carrier and payments are coordinated with the other carrier.
- I have also worked on a fast track property claims team working to quickly resolve minor property damage claims while delivering customer service.
0-5 years of experience
- Participated in the transition of over 5,000 open workers’ compensation claims transferring from one TPA to Frank Gates.
- Responsibilities encompassed specialization in initial claim investigations, identification of subrogation issues, oversight of surveillance and overall management of claims practices and reserving policies.
- Attended multiple Serious Case Reviews to specifically address legal issues and staff aggressive plans of action.
- Responsible for ongoing management of appropriate claims reserving and constant communication with nationwide account related financial issues impacting loss ratios.
- Participated in the implementation of MPN Network and roll out with multiple facilities.
- Worked diligently the on-site nurse case managers to strictly enforce ACOEM guidelines.
- Member of 2 investigation teams, which included development of a litigation plan, taking recorded statements, identifying subrogation issues, and management of subrosa and investigations.
- Worked closely with attorneys, vocational rehabilitation counselors, underwriters, bill review representatives, and nurse case managers.
- Assisted in training and was appointed to several committees for the educational expansion of employees and employers.
0-5 years of experience
Administers all Medicare UB claims adjudication processed in accordance with contractual guidelines along with [company name] guidelines.
- Retrieve Medicare UB claims in accordance with departmental guidelines and adjudicate based on contractual guidelines wile applying all relevant policies and procedure.
- Research pended Medicare UB claims in accordance with departmental policies and procedures.
- Determine payment or denial of Medicare UB claims while applying appropriate codes as necessary for denied claims.
- Maintain production and quality goals.
6-10 years of experience
Responsible for management of up to 120 claims for dedicated unit
- Coordinated management requirements with client guidelines
- Management claimant benefits and issued required benefit notices
- Resolved litigated and in pro per claims and resolved liens
10+ years of experience
Process general, product, and auto liability claims for all Masco business units
- Work closely with the Business Unit Financial personnel managing their claims and risk
- Delegate and supervise the investigation of all assigned claims
- Review insurance policies for coverage determination
- Communicate effectively with claimants, insurance companies, and attorneys
- Negotiate settlement of all assigned claims
0-5 years of experience
- Review policy file to determine correct beneficiary and establish available death benefit options.
- Analyze completed claim forms, and other documents submitted with claim such as death certificates, letters testamentary and determine when claim is available for payment, in compliance with policy provisions, state and federal regulations.
- Maintain working knowledge of claim practices, policies and procedures.
- Identify and escalate complex related claims and research items to Claims Risk Management team for further handling.
- Developed and implemented Quality Assurance metrics for Annuity Claims Department.
0-5 years of experience
Preparing Medicare beneficiary documents for Qualified Independent Contractor evaluation
- Keying paper insurance claims for verification
- Evaluating and correcting on-line Medicare claim errors
- Accessing and applying on-line instructions for the proper resolution of claims suspensions
- Manually pricing and adjudicating suspended claims
0-5 years of experience
Process complex Medicare, Medicaid & private insurance claims
- Investigate and code member submitted claims
- Investigate DME claims up to 5 years back
- Resolve pending claims & process adjustments
- Knowledge of ICD-9 codes and CPT Modifiers
- Contact providers office for additional information
0-5 years of experience
Validate claims based on claim department workflows
- Monitor claims based on compliance regulation and timeframes
- Perform manual data entry of claims with appropriate information as required
- Maintain quality and productivity standards as set by management
- Review the rejected claim file received from vendors to determine appropriate course of action
- Assist Supervisor in monitoring claim turnaround time (TAT)
- Responsible for sending misrouted claims to the appropriate group within 10 (ten) business days
- Update and prepare reports for management team as assigned
0-5 years of experience
- Familiar with standard concepts, practices, and procedures within a particular field.
- Examines claims material to ensure insurance coverage and validity.
- Has contact with agents, claimants, and policy holders.
- Reviews, evaluates and processes disability insurance claims according to procedure and practice.
- Examines claims material to ensure insurance coverage and validity.
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Claims Examiner
Last edited by: Gabriela Barcenas, CONTENT STRATEGIST -
Gabriela Barcenas
CONTENT STRATEGISTGabriela is a Certified Professional Resume Writer (CPRW) and career adviser. With 10 years of digital media experience and five years of resume writing expertise, her publication history includes fashion, education, travel, social justice, equitable design and career advice.
