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Claims Specialist Resume Samples
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0-5 years of experience
- Assisted claim adjusters by timely and accurately recording and processing over 500 property damage claims per month
- Provided on-going customer support for dealers and customers, resulting in increased satisfaction and retention
- Supported internal insurance agents by managing telephone inquiries, processing outbound mail, maintaining customer records, and administering to customer and dealer requests
- Tracked and maintained theft histories and recoveries, resulting in 1M annual recovery proceeds of stolen equipment
0-5 years of experience
Audited claims in NextGen database, ensuring that claims were processed correctly according to state guidelines
- Assisted adjusters in making expense payments on EagleView invoices
- Conducted outbound calls to customers to recover overpayment and resolve duplicate payments; processed PCR reports in NextGen to make sure the claims were properly handled
- Researched unpaid and duplicate payments made to EagleView, identified situations where claims need to be paid or refunded
0-5 years of experience
- Administered a high volume of NY No-Fault claim files by utilizing daily diary systems to prepare and release all state mandated forms and letters.
- Recognized the potential of possible fraudulent claims; submitting to the special investigations unit with close monitoring.
- Analyzed bills for authorization of delay, denial or payment; opening reserves on the file to reflect the extent of injuries.
- Negotiated and prepared claim files for arbitrations, suits, summons defense.
- Calculated loss wages and essential services while keeping current on the NY No-Fault Fee Schedule, CPT book and ICD-9 coding specific guidelines.
- Handled heavy volume of phone calls from medical providers and attorneys’ offices; maintaining constant communication with the injured parties throughout the life of the No-Fault claim.
- Ordered, reviewed police reports, DMV checks and CIB reports; resolved and defended billing allowances and reductions.
0-5 years of experience
- Streamlined insurance processes and introduced process improvements to enhanced productivity
- Served as a team leader to provide procedural direction and guidance to new team members
- Achieved success assisting clients face to face, over the phone and electronically to resolve questions and concerns while explaining products and services to help settle property claims
- Developed new business opportunities through target marketing and maintaining strong relationships
0-5 years of experience
- Set up an average of 85 reported life and health insurance claims per day.
- Generated daily status letters to beneficiaries, concluding with claims forms obtained on 90% of pending claims, within 6 months of claim notice.
- Trained and mentored two claim specialists.
- Administered departmental outlook mailbox and acted on claims documentation within a business day.
- Responded to internal and external customer service requests.
0-5 years of experience
- Diligently assessed customer problems and created claim resolutions
- Effectively improved customer retention by issuing credits on damaged orders
- Thoroughly provided customers with detailed information on their claims by referencing the terms of use and the policy information
- Independently made claim decisions within authority based on the information given by the customer
0-5 years of experience
- Received claims (workers’ compensation, commercial property, auto, and liability) and prioritized their urgency by analyzing case information.
- Developed process for state form filings, reducing compliance fines and increasing accuracy.
- Interpreted individual state regulations in order to determine what filings needed to be submitted and what benefits were owed; contacted other departments and / or state agencies as required.
- Utilized time management skills to ensure that all filings and requests from individual state agencies were completed in the allotted time frames.
10+ years of experience
- Conducted prompt and thorough investigations of bodily injury auto insurance claims.
- Analyzed claims to determine the extent of Company’s liability, make approval or denial decisions and negotiate fair settlements with claimants in accordance with policy provisions.
- Provided optimum service to policyholders and claimants.
- Established and maintained high level of positive working relationships with internal and external customers, ensuring satisfaction with company services.
- Recognized for supporting company, business unit, and department’s vision and mission.
- Excelled at oral and written communication; time management.
6-10 years of experience
Performed managerial duties in the absence of the PIP manager. Evaluated policy coverage and processed payments for medical and commercial Personal Injury Protection claims. Reviewed and approved medical necessity requests. Recommend lifetime
reserves for catastrophic claims. Researched medical information and referred claims for PEER review.
- Created training manual for processing commercial PIP claims.
- Trained new employees hired into the unit and reviewed their work output.
- Developed and suggested new procedures to enhance workflow with the team.
0-5 years of experience
- Conducted one-on-one and classroom training sessions for new and existing employees
- Reviewed and analyzed policy language and supporting documentation in order to accurately adjudicate accident claims
- Adhered to HIPAA guidelines and privacy rules while consistently exceeding quality and production metrics
- Provided guidance to internal and external customers through verbal and written communication
- Routinely assisted with hospital indemnity claim processing
0-5 years of experience
- Managed large caseload of commercial general liability claims involving bodily injury including analysis of complex coverage issues including reservation of rights, coverage declinations and tenders of defense, negotiation of litigated and non-litigated claims.
- Monitored and controlled defense costs of litigated files through scheduled litigation plans/budgets with defense counsel.
- Compliance with Department of Insurance, investigative and reserving practices, diary management and closures.
- Involved in intra-company volunteer positions including Employee Club, Grass Roots Improvement Committee, Community Outreach and Employee Survey Result Committee.
10+ years of experience
- Validated all claims completely and accurately.
- Reviewed determined and released reimbursements to various customers.
- Performed all work in accordance with customer and company standards.
- Provided excellent customer service to members and went above my duties to resolve any claims or benefits issues
0-5 years of experience
- Received Shining STAR Award for excellence processing 30 claims per hour
- Exceeded overall audit average benchmark of 95% accuracy
- Priced Autism and mental health claims with provider contracted rate and forwarded to Corporate for payment
- Handled first-time claims submitted late by the provider, then emailed to HBH for pricing
- Reviewed member benefits to resolve incorrect copays
- Appeals & Grievances
0-5 years of experience
- Provided remarkable customer service to internal and external customers.
- Worked auto claims from the initial loss reporting, through completing liability investigations, and advising customers of liability decisions.
- Reviewed customer insurance policies, and advised customers of coverages available for the reported loss.
0-5 years of experience
- Acquired contracts.
- Consulted clients on their hail or wind property claims and met with insurance adjusters to inspect damages.
- Worked with insurance companies to properly indemnify clients.
- Oversaw construction till completion.
- Brought in 500k in company revenue in 5 months.
0-5 years of experience
As a Claims Specialist, my job is reviewing insurance claims after they are submitted to make sure that proper filing procedures have been followed. I also assist insurance adjusters with complicated or unusual claims.
- Determines covered medical insurance losses by studying provisions of policy or certificate.
- Establishes proof of loss by studying medical documentation; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims.
- Documents medical claims actions by completing forms, reports, logs, and records.
- Resolves medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter.
- Ensures legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
0-5 years of experience
- Responded attentively to providers and member questions via telephone and written correspondence with regards to identified issues on insurance benefits, provider contracts, eligibility, and claims.
- Performed a thorough analysis and resolution of Medicaid/Medicare products for provider bill claims.
- Responsibilities included overall monitoring of out-patient procedure authorizations and in-patient hospitalizations treatment as well as level-of-care changes and rehabilitation therapy evaluations.
- Extracted data from databases and entered on spreadsheets for follow up on all high-level discrepancies.
- Routinely analyzed problems and provided information/solutions for accurate tracking and analysis.
- Operated a PC/image station to obtain and extract information; documented information and activities.
- Developed and maintained positive customer relations and coordinated with various functions within the company to ensure customer requests and questions were handled appropriately and in a timely manner.
- Researched and analyzed data to address operational challenges on provider and member service issues.
0-5 years of experience
Evaluated insurance polices and analyzed damages to determine coverage
- Investigated claims involving potential and suspected fraudulent activities
- Substantiated legitimate claims and denied unjustified claims
- Documented all investigation activities and presented reports to management
0-5 years of experience
- Investigate incoming property damage claims on behalf of the company.
- Invoice the damaging party, pursue for collections efforts. SAP trained for invoicing. $1 million plus invoiced to date. Strong negotiation and customer service skills.
- Attend Trials, mediation on behalf of the company. Familiar with FL statues the govern construction. Work closely with in house Counsel. Compliance with regulatory bodies and Public Service Commission.
- Knowledge of the Utility distribution system. Ability to build relationships with distribution staff. Self-Insured company.
- Daily use of Excel for various tracking activities. Monthly reconciliation of trial balance. Utilize Riskmaster claims system.
- Build relationships with internal and external customers. Communicate decisions effectively. Proven leader on claims team consistently takes on projects in the corporate office. Mentored new hire.
0-5 years of experience
- Accurately billed large Insurance Companies for durable medical equipment.
- Processed Claims precisely and assisted clients with various billing inquiries.
- Applied adjustments and credits to patients’ accounts.
- Ordered all supplies needed to support durable medical equipment.
- Consistently achieved company quota on a month to month basis
0-5 years of experience
- Took complete loss report information.
- Established and maintained strong relationships with customers, built credibility and gained trust while operating with integrity at all times.
- Utilized verbal and critical thinking skills to gather information and data; making sound decisions
- Reviewed insurance policy to determine coverage and application.
- Set up rental car reservations and appointments for vehicle inspection/repair.
0-5 years of experience
Managed and investigated auto claims as an examiner for both liability and no-fault.
- Investigated loss facts to determine a liability decision.
- Negotiated with adverse carriers to resolve liability disputes.
- Evaluated policy coverage and educating involved parties of the claims handling procedure.
- Sent correspondence and completing actions all within state regulated timeframes.
- Medical claim management including issuing payments for medical billing and expenses.
- Counseled customers on their auto claim needs.
- Assisted customers with their first notice of loss for physical damage, theft, & comprehensive claims.
- Educated customers on insurance coverages and limits while providing excellent customer service.
- Monitored claims for fraud and bodily injury exposures.
0-5 years of experience
- Works with our Complex Settlement Administration and provide aspects of the litigations to ensure enrolling claimants are in a position to make informed decisions.
- Educate participating claimants about the potential impact settlement complications may have on certain government benefits, such as SSI and Medicaid.
- Inform participating claimants of options they may have to preserve such benefits and direct claimants to appropriate resources.
- Answer claimant questions regarding Medicare, Medicaid, ERISA / Private, and all other types of healthcare lien resolution.
- Process CMS-1500 and UB04 forms from patients and ensure correct procedures for processing and adjudicating claims.
0-5 years of experience
- Conducted the investigation of surety claims in a timely, efficient, courteous and professional manner
- Reviewed and evaluated coverage and /or liability
- Communicated with claimants, trustors/principals and CBP regarding claim files
- Secured and analyzed necessary information (reports, policies​, statements, or other documents) in the investigation of claims
- Conveyed more complex information (coverage, decisions, outcomes, negotiations, etc.) to all appropriate parties
- Drafted claim denials to claimants based on claim research
- Ensured that claims payments are issued in a timely and accurate manner
- Ensured that claims handling is conducted in compliance with applicable statutes, regulations and other legal requirements and that all applicable company procedures and policies are followed
- Filed petitions with CBP when necessary
6-10 years of experience
Accountable for evaluating and investigating complex claims on commercial, general liability and self-retained insurance exposures.
- Perform supervisory functions including: monthly auditing of files, assignment of new claims, interviewing prospective employees, approval of payments, meeting with clients and training of staff.
- Participate on multiple project management teams to create, implement and train staff on new claims management software program and claim handling guidelines.
- Negotiate and settle all aspects of claims involving litigation, coverage disputes/investigations, property damage and bodily injury.
- Attend mediations, arbitrations and trials.
0-5 years of experience
- Use established procedures, scripts and job aids while navigating multiple computer applications
- Initiate claims process as reported by insured, client or other interest.
- Describe claims process to customers
- Update and maintain customer’s information
- Escalate problems or inquiries to appropriate department or authority
- Maintain quality, accuracy and professionalism in a fast-paced environment
0-5 years of experience
Data entry/adjudication of 100+ Physician and Hospital claims, (Medicaid and Medicare) into Quick Cap (Medical billing system).
- Review of Provider information, Tax ID, address and Hospital affiliation for billing purposes.
- Attached authorization if needed and updated referrals for adjudication process.
- Evaluation of Quick Cap for denial/payment accuracy of all claims.
- Utilize 3M Pricing Tool for all Impatient and most Outpatient claims to determine cost of medical services.
0-5 years of experience
- Independently determined and established entitlement of monetary benefits to claimants and their beneficiaries under various Social Security programs: Disability, Retirement, Medicare and Supplemental Security Income (SSI).
- Obtained and verified information, such as valid citizenship, age and eligibility used to analyze claims and make independent decisions regarding entitlement to benefits.
- Provided exceptional customer service by interacting with public face-to-face or by telephone to provide benefit payment amounts.
- Addressed a wide variety of questions by interviewing the individual, investigating the situation and resolving the problem.
- Adjudicated claims using complex automated operating database systems once eligibility and entitlement has been established.
- Accessed and referred to multiple queries to collect complex benefit data and determine eligibility.
- Maintained multiple electronic files by uploading and scanning documents and records.
- Attended weekly staff operational transmittal training, and On-The-Job (OJT) training periodically.
0-5 years of experience
- Respond to customer inquiries and third party carrier inquiries, keep all scheduled call appointments.
- Analyze all matters identified with subrogation recovery potential as it relates to automobile property damage: Rental, Lost Wages, Car Seats, vehicle damage, front/rear Splits.
- Issue Deductible payments, prepare claims for Litigation/Arbitration
- Communicate with Third party carrier on payment status and provide updated supplements via E- subrogation Electronic hub database
0-5 years of experience
Specialized training in data keying on the company’s computer.
- Assessing Claimants’ files submitted for claims.
- Handled required data work for the Claimants’ by performing skilled detailed assignments.
- Helped in assessing the Claimant’s forms work on time.
0-5 years of experience
- Research and make benefit determination for the processing of Medicare and Medicaid member claims according to processing guidelines
- Maintain production and quality standards while performing high volume data entry
- Investigate claims for required processing information
- Processed special situation claims, including Clinical Trials, Dual [company name] Coverage, and Referrals
- Helped do bail out work for other departments, including Department of Public Aid, Nervous Mental, [company name] One, and Initial Claims
- Shining STAR Award Recipient
- Selected to be an Ambassador on the Inclusion and Diversity Team
0-5 years of experience
- SME to Claims support teams across the United States
- Testing systems configurations and operational support for new business lines to assure systems are properly configured correctly. Identifying error trends and resolutions and performing regression testing.
- Train new hires and cross training of team members on specialized contracts and processing claims
- Process claims, adjustments, and appeals when teams are receiving heavy volume of work to make sure they are processed within contracted time frames.
0-5 years of experience
- Process death, maturity and disability claims pursuant to Association bylaws and procedures and in compliance with all statutes and the State Code
- Process claims in an efficient, timely manner.
- Research exceptions and, when supervisor counsel is required, provided analysis and proposed solutions for considerations
- Establish and maintain positive member, beneficiary and agent relationships
- Review, create and modify all legal documents required for death claims in order to keep to company safe from lawsuits in the process
- Provide the company any interpretation services as needed
0-5 years of experience
- Experience with commercial, farm/ranch, homeowners, and boat claims
- Obtained CPCU designation in less than 2 years (100% pass rate)
- Tactfully communicate with policyholders, contractors, and management
- Objectively assess property and financial loss and present claim settlements
0-5 years of experience
- Received inbound calls from customers inquiring about cellular phone or wifi device claims.
- Established rapport and provided positive resolutions to customers unsure of the claims process versus having a warranty
- Processed claims to ensure clients received replacement cellphones, wifi tablets or laptops for their damaged, broken, or lost devices.
0-5 years of experience
- Responsible for accurate claims processing for all states
- Responsible for navigating through the computer based claims manual
- Ability to maintain accurate records in excel, word and power point
- Responsible for maintaining company quality standards of 98% or higher.
0-5 years of experience
Receptionist
- Verified patients’ eligibility and claims status with insurance agencies
- Responded to correspondence from insurance companies
- Posted and adjusted payments from insurance companies
- Examined patients’ insurance coverage, deductibles, possible insurance carrier payments and remaining balances not covered under their policies when applicable
- Processed accounts receivable
- Provided exceptional customer service
0-5 years of experience
- Investigate claims from initial report to completion of claim by interviewing policyholders and claimants, and arranging inspection of property damage
- Determine liability by gathering pertinent evidence including: recorded statements, police reports, witness statement, scene photos, and vehicle damages
- Identify appropriate exposures and set loss reserves while profiting the company
- Prioritize daily activities on file to effectively resolve customer claims while handling six to eight claims at a time
- Communicate via telephone or email with policyholders, claimant carriers, attorneys, body shops, and other vendors
0-5 years of experience
Investigates and bills workers compensation claims and resolves troubled and or denied workers compensation claims.
- Reviews provider account notes and account history. Obtains accident details, employer contact information and workers comp insurance carrier information.
- Bills worker’s comp carriers and employers.
- Performs follow up activities with employers, carriers, adjusters and patients.
- Resolves regular, disputed, and denied accounts through communication with adjusters and patients.
0-5 years of experience
Guiding clients through the auto/property or health insurance claims process step by step.
- Working directly with insurance companies and health providers to resolve any and all conflicts for our clients.
- Analysis, negotiation and reprocessing of medical invoices.
- Consistent follow up with all parties relative to a claim to process it as efficiently as possible.
0-5 years of experience
Proofread and general administrative work with a high level of attention to detail abilities.
- Claims management, workers compensation, disability claims, and credentialing and/or medical administration.
- Communicate with customers, remote team members and external contacts to gather and clarify details.
- Coordinating the IME/disability claims review process including data entry, scheduling reviewers and facilitating the workflow process.
- Proofreading and general administrative work.
- Negotiating payments to Physicians as well as vendors for peer to peer referrals.
0-5 years of experience
- Hail Reconciliation Licensed Unit
- Handled Hail and Wind Homeowner Claims
- Created Estimates with Xactimate 28 Program
- Reconciled Estimates and Issued Payments
- Taught Claim Procedures to Team
- Led Team Meetings Once a Month
10+ years of experience
Handle complex professional liability, Civil Rights and Employment Litigation
- Personally attend mediations (30 mediations since 2012) and Trials
- Successfully defended cases through trial and Motion for Summary Judgment
- Attended Oral Arguments at Commonwealth Court, 3rd Circuit and En Banc Hearings
- Handle High Profile Cases
- Manage Attorney Panel List and Negotiate Attorneys’ Fees
- Liaison for Attorneys and Claims Director
- Liaison for Attorneys and Legal Solutions
- Coordinate Seminars for Claims Director
0-5 years of experience
- Providing expertise or general claims support by reviewing EOB, COB, researching, investigating, negotiating, processing and adjusting claims
- Authorizing the appropriate payment or referring claims to investigators for further review
- Conducting data entry and re-work; analyzing and identifying trends and providing reports as necessary
- Using of CPT and ICD code in calculating other insurance and re-pricing benefits
- Working claims and UB-04 and HCFA files to ensure the appropriate eligibility and provider records are matched to the claim
0-5 years of experience
- Serve as the primary point of contact for customers reporting first notice of loss.
- Respond to customers’ claim requests and coordinate with the appropriate business partner for resolution.
- Make and maintain a connection with the customer by understanding and meeting their needs.
- Work closely with claim leaders on a daily basis to update daily productivity results and goals.
- Share experience and knowledge of the claims process with new team members.
- Key member of a team responsible for continuous improvement initiatives to improve customer satisfaction and retention.
- Participate in departmental sponsored activities such as: Engagement Committee and Community Involvement activities.
10+ years of experience
- Reviewed claim estimates for payment and processed payment
- Reviewed Roadside Assistance Claim for payment and processed payment
- Subrogation Claims Specialist
- Recapture (cost saving) on auto estimates
- Documented information regarding Fraudulent claims and submitted to SIU
- Supervisor for Auto Claims Rental Car Department
0-5 years of experience
- Check providers charting for any errors before submitting claims electronically
- Follow up on claims that have not been paid by insurance companies and submit corrected claims if needed
- Make appeals to insurance companies as needed
- Follow up on balances due by patients
- Credential doctors
0-5 years of experience
- Examine claims forms and other records to determine insurance coverage.
- Investigate and assess damage to property and create or review property
- Interview or correspond with claimants, witnesses, police or other relevant parties to determine claim settlement, denial, or review.
- Review police reports or physical property damage to determine the extent of liability.
- Analyze information gathered by investigation, and report findings and recommendations.
- Interview or correspond with agents and claimants to correct errors or omissions and to investigate questionable claims.
0-5 years of experience
- Assisted consumers with processing auto claims
- Resolved escalated customer service issues
- Assisted with bilingual/Spanish consumers
- Data entry
- Customer communication, both written and verbal
- Summarization and reporting of customer impact issues
0-5 years of experience
- Determines covered medical insurance losses by studying provisions of policy or certificate.
- Documents medical claims actions by completing forms, reports, logs, and records.
- Research and Post adjustments
- Medical billing ub04 and hcfa-1500
- Medicare/ DDE
- Check each insurance payment is for accuracy and compliance with contract discount
- Call insurance companies regarding any discrepancy in payments if necessary
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Claims Specialist
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.
