Claim Examiner Resume Samples

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J Barrows

Jody

Barrows

447 Farrell Row

San Francisco

+1 (555) 426 6741

447 Farrell Row

San Francisco

Phone

p +1 (555) 426 6741

Experience Experience

Chicago, IL

Claim Examiner

Chicago, IL

Kuphal-Funk

Chicago, IL

Claim Examiner

Performs other duties as assigned by management
Analyzes claims activities and prepares reports for clients, carriers and/or management. Participates in claim reviews
Interprets and makes decisions using independent judgment on more complex and unusual policy coverages and determines if coverages apply to claims submitted
Develops subrogation and third party recovery potential and follows reclaim procedures
Make settlement decisions promptly and equitably and issues company drafts in payments for claims within authority limits
Functions as a resource for examiners and assist with training new examiners and customer service representative
Analyzes claims activity and prepares reports for clients/carriers and management

New York, NY

Property Claim Examiner

New York, NY

Murazik, Jacobs and Robel

New York, NY

Property Claim Examiner

Willing to be flexible in work hours (rotating late shift, occasional Saturday, overtime for CAT)
Successfully contribute to the development and delivery of the team’s goals, objectives and results
Develop and maintain strong business relationships with internal and external customers
Recognize and identify potential fraudulent claims. Effectively control the use, work product, and expenses of outside vendors
Analyze first reports and promptly contacting insured/claimants
Effectively evaluate claim facts and negotiate claim settlements
Recognize and pursue recovery. Adhere to all statutory and regulatory fair claims practices

present

New York, NY

Group Life Waiver of Premium Claim Examiner

New York, NY

Hintz-Nienow

present

New York, NY

Group Life Waiver of Premium Claim Examiner

present

Supports continuous process improvement and total performance management culture
Review, investigate, identify issues and develop sufficient valid evidence to make objective claim eligibility determinations
Provide superior customer service to internal and external customers
Provide conversion rights at benefit reduction and benefit termination
Analyze physical capacity forms and medical records
Clearly and accurately communicate claim decisions to policyholders and claimants
Maintain claim files in a manner defensible in court with thorough, clear and objective claim documentation

Education Education

Bachelor’s Degree in Accuracy

University of Illinois at Chicago

Bachelor’s Degree in Accuracy

Skills Skills

Partners with Advocacy Triage team to ensure timely response to critical and non-critical Advocacy cases
Acts as a knowledge resource for all items related to participant claims and/or access-to-care issues
Detailed knowledge of, and experience in, health plan claim processing / insurance claims processing and customer service functions or extensive medical insurance billing & coding and follow up
Familiar with various types of medical plans and knowledge of client plan provisions
Consistent research and follow up skills; collects pertinent information from participants, documents the information concisely, conducts thorough research and follows up with participants within the appropriate timeframe
Well-developed problem-solving skills working closely with the insurance health carriers
Collects pertinent information from participants, documents the information concisely, conducts thorough research and follows up with participants within the appropriate timeframe
Identifies trends and is able to provide client-ready trend analysis
Working knowledge of word processing, spreadsheet and Microsoft Office applications
Manage the expenses associated with any assigned claim to achieve satisfactory results on both expense and indemnity costs

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Claim Examiner Resume Examples & Samples

Partners with Advocacy Triage team to ensure timely response to critical and non-critical Advocacy cases
Acts as a knowledge resource for all items related to participant claims and/or access-to-care issues
Detailed knowledge of, and experience in, health plan claim processing / insurance claims processing and customer service functions or extensive medical insurance billing & coding and follow up
Familiar with various types of medical plans and knowledge of client plan provisions
Consistent research and follow up skills; collects pertinent information from participants, documents the information concisely, conducts thorough research and follows up with participants within the appropriate timeframe
Well-developed problem-solving skills working closely with the insurance health carriers
Collects pertinent information from participants, documents the information concisely, conducts thorough research and follows up with participants within the appropriate timeframe
Identifies trends and is able to provide client-ready trend analysis
High School diploma or G.E.D. required
Detailed knowledge of and experience in health plan claim processing and/or extensive medical insurance claims processing and/or medical billing & coding research required
Possesses the analytical evaluative skills of a claim examiner
2 plus years of in-depth experience of all types of medical plans (HDHP, PPO, HMO, etc.) required
Ability to understand / interpret client plan provisions
Effective communication with health plan vendor contacts to ensure highest level of service for participant
Accurate and consistent research and follow up skills
Well-developed problem-solving skills
Work Schedule, Monday - Friday 9:30AM - 6:00PM

Living Benefit Claim Examiner Resume Examples & Samples

Conducts correspondence related to client requests for information
Evaluates available information to validate claims. Verifies policyholder information, policy effective dates, premium status and verification of claim eligibility
Investigates moderate to highly complex claims and determines level or resolution if appropriate; advises claimant of status; assists in negotiating settlement and resolution of claim
Receives demand letters; researches and investigates claims, responds within individual parameters and escalates as appropriate
Fellowship of Life Health Claims (FLHC) Certification preferred
. At least 2 years of life insurance experience 2. At least 1 year of experience in living benefit Claims (waiver, accelerated benefits, A&H) 3. Proficiency with MS Office (word, excel)
Good negotiation skills to interact with claimant

Claim Examiner Resume Examples & Samples

The Claims Specialist sets adequate reserves to ensure proper reporting
Liaison with Marketing/Customer Service departments
Approves claims at the appropriately demonstrated assigned authority level
1 – 3 years CLAIMS ADJUDICATION experience
Ability to multi-task – manages time effectively

Claim Examiner Resume Examples & Samples

We do the right thing
People count
We hold ourselves to very high standards

Insurance Claim Examiner Resume Examples & Samples

Determine plan liability as well as diversion and recovery activity for claims
Identify and resolve claims pending
Integrate and use knowledge and experience as a skilled specialist

Claim Examiner Resume Examples & Samples

Independently reviews and evaluates claims submitted on the Company’s life, annuity, health and disability products. Determines the Company’s liability using knowledge of policy provisions, medical terminology, disability duration, state regulations and tax requirements
Assures claim processing and payment procedures for death, cancer, ordinary/industrial accident and health and total and permanent disability claims according to Company procedures meet the appropriate state regulations
Determines proper payees, calculates benefits and releases payments within authorized limits to assure that the Company is fully discharged from liabilities associated with claims
Conducts and controls investigations on contestable and accident claims on policies with face amounts under $10,000 and claims for disability premium waiver. Exercises independent judgment in defining the nature and scope of the investigation. Selects outside investigation firms when appropriate and manages the costs associated with each investigation
Works directly with our Law Department to draft legal releases, affidavits, authorizations and agreements to settle a claim
Identifies claims that meet qualifications for payment via Life Accounts and completes processing necessary to set up the accounts
Conveys claim decisions to the beneficiary through reasoned, clear, concise and well-constructed written correspondence while following proper rules of punctuation, grammar, dictation and style
Reviews their own and other associates’ paid claims for accuracy and completeness. Verifies that all needed information was received, and codes statistical data regarding cause of death as required
Provides guidance and direction to the claim approver staff on claim issues including payee problems, accounting discrepancies and transaction errors
Provides concurrence for other Senior Approvers on contestable claim payments. Concurs with Claim Analyst on contestable claim rejections
Inputs claims into systems, maintains pending files, matches output to the appropriate file and distributes new mail
Responsible for completing project work as assigned by management. Projects include but are not limited to completing various monthly, quarterly and yearly reports
Provides prompt and courteous handling of escalated and second-level calls routed from the Customer Service representatives including coverage questions, complaints related to benefit decisions and explanations of claim requirements providing clear, concise and accurate information to the caller
Demonstrated knowledge of claims administration including payment options, contract provisions and tax ramifications
Must provide examples from work experience of maintaining a high degree of accuracy and excellent organizational skills associated with high volumes of work and/or multiple duties
Demonstrated knowledge and experience with various claims administration systems and/or processes. Ability to continuously make repetitive motions of the wrists, hands and/or fingers
Demonstrated experience working effectively within a team. Must provide examples from work experience of going beyond the call of duty to assist team members
Demonstrated excellent verbal and written communication skills with the ability to successfully interpret and communicate business needs to internal or external customers in a clear, focused and concise manner. This would include strong telephone communication and etiquette skills
Proven experience adapting and demonstrating flexibility associated with changes to policies/procedures
Demonstrated experience acquiring and assimilating new knowledge and skills. Must be able to cite examples of work experience wherein new skills were applied to complete assigned tasks successfully
Experience must include identifying and resolving problems where independent decision-making and initiative were demonstrated. Must provide examples of working under multiple deadlines and minimal supervision
Demonstrated experience and proven strong analytical skills in identifying and quantifying problems arising from customer, policy/procedural changes, etc., and providing effective recommendations to resolve
Working knowledge of word processing, spreadsheet and Microsoft Office applications

Claim Examiner Resume Examples & Samples

Interprets and makes decisions using independent judgment on moderate difficulty claims and policy coverages and determines if coverages apply to claims submitted
Investigates, evaluates, negotiates and adjudicates first and third party claims to determine validity and verify extent of damage by telephone contact with clients, claimants, witnesses or other parties as required
Make settlement decisions promptly and equitably and issues company drafts in payments for claims within authority limits

DI Claim Examiner Resume Examples & Samples

Recommending initial and ongoing liability determinations on disability income and life waiver of premium claims and authorizing benefit payments as appropriate within specified authority limits
Properly adjudicating disability income and life waiver of premium claims
1+ years of customer service experience, required
4 year college degree or equivalent of work experience, required
Exceptional customer service skills through oral and written communications is required in accordance with internal and regulatory standards
Candidate must have the ability to work in the US without requiring sponsorship
Must be flexible, able to work independently and self-driven
Knowledge of MM Systems, preferred

Insurance Claim Examiner Resume Examples & Samples

A minimum of 2+ years of insurance industry experience, prefer previous experience working with health claims
Excellent communication skills, both verbal and written (communicate effectively with internal and external customers)
Proven ability to read, analyze, and interpret general business communications
Knowledge of Medical Terminology, Anatomy & Physiology, Disease Process, and Pharmacology is preferred
Knowledge of CPT, ICD9 and ICD10 codes and insurance billing forms helpful
Past demonstrated experience in the ability to apply business rules to varying fact situations and make appropriate decisions

Property Claim Examiner Resume Examples & Samples

Paid holidays
Year-end bonus program
Access to continuing education via the Kelly Learning Center
Analyze first reports and promptly contacting insured/claimants
Effectively evaluate contract language and identify coverage issues
Promptly and appropriately develop the file to provide accurate and timely investigation and loss analysis. Maintain an active file diary to more file toward resolution
Recognize and pursue recovery. Adhere to all statutory and regulatory fair claims practices
Recognize and identify potential fraudulent claims. Effectively control the use, work product, and expenses of outside vendors
Effectively evaluate claim facts and negotiate claim settlements
Develop and maintain strong business relationships with internal and external customers
Serve as a technical resource to lesser experienced Adjusters on the team
Successfully contribute to the development and delivery of the team’s goals, objectives and results
Supports workload surges and/or Catastrophe Operations as needed to include working overtime during designated CATs
Bachelor's Degree preferred or equivalent experience with a minimum of two years of property claims adjusting experience. Commercial claims adjusting preferred but not required
Very comfortable working with computers including taking notes while on the phone while toggling between different computer programs
Full knowledge of insurance contracts, investigation techniques, legal requirements, and insurance regulations a plus
Willing to be flexible in work hours (rotating late shift, occasional Saturday, overtime for CAT)
Current Claims Adjuster licenses in one or more states preferred but must be willing to obtain additional state licensures
Important information: This position is recruited for by a remote Kelly office, not your local Kelly branch. Please submit your resume to be considered for this position by pressing the “SUBMIT RESUME” button below. If you have questions about the position, you may contact the recruiter recruiting for this position (mick595@kellyfinance.com), however, your resume should be uploaded via the “SUBMIT RESUME” button included within**

Group Life Waiver of Premium Claim Examiner Resume Examples & Samples

Accurately interpret and apply group life contracts in determining eligibility
Analyze physical capacity forms and medical records
Assess LTD claim for additional information using our integrated claims platform
Conduct annual medical reviews and claim reassessments as appropriate
Provide conversion rights at benefit reduction and benefit termination
Clearly and accurately communicate claim decisions to policyholders and claimants
Coach policyholder on the administration of the group life waiver of premium benefits
Provide phone back-up for Customer Service when required

Claim Examiner Resume Examples & Samples

Provide superior customer service to our
Manage the expenses associated with any assigned claim to achieve satisfactory results on both expense and indemnity costs
Maintains electronic records that accurately and thoroughly document all file handling activity
Overnight travel will be required occasionally including but not limited to attendance at mediations, trials, etc
May be called upon to perform additional duties as directed
7 years or more claims handling experience preferred
High school degree or equivalent; college degree preferred
Insurance designation preferred
Basic computer skills and Microsoft applications

Claim Examiner Workers Comp-area Resume Examples & Samples

Receives claim assignment, confirms policy coverages and directs acknowledgement of claims
Analyzes claims activity and prepares reports for clients/carriers and management
Analyzes claims activities and prepares reports for clients, carriers and/or management. Participates in claim reviews

Claim Examiner Resume Examples & Samples

2-3 years' experience in a medical claims processing environment
Must be extremely detail-oriented, precise, and thorough
Extensive knowledge of medical claim processing procedures and guidelines
Ability to work independently while providing support to a team environment
Knowledge of medical benefits and medical terminology
Must have strong organizational skills, problem solving, and decision making skills
Knowledge of claim adjudication and benefit plan application for Texas Medicaid
Able to process adjustments as needed
Knowledge of Microsoft Office Skills including Word, and Excel

Individual Claim Examiner Resume Examples & Samples

Responsible for Life and Annuity claims (both contestable and non-contestable), Accidental death, foreign deaths, homicides and DBAR claims within an authority level of $125,000.00; any claim over this amount requires review and approval by the Claims Specialist, Senior Examiner, Team Leader or the Manager
Follows established Ameritas claim procedures and guidelines to conducts claim investigations and make appropriate claim decisions. Organize, plan and priority work in order to accomplish goals established for the position
Requires basic knowledge and experience in claim adjudication
Works effectively with the Claims Specialists, Trainer and Manager to continue developing claim handling skills and to make appropriate claim decisions
Develops and maintains good rapport/communication with the field representatives, claimants, agents, claimant attorneys, reinsurers, Medical Director and the law department
Develops professional and technical knowledge by attending continuing education opportunities (workshops, fraud training, claims conferences, etc.)
Required to participate in depositions, court appearances and negotiations regarding settlement options
Participates/presents claims to the SIU
Works effectively with the reinsurers
Utilizes vendors appropriately to conduct claims investigations