Manager, Claims Resume Samples

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E Langosh

Erin

Langosh

4412 Purdy Shores

New York

+1 (555) 909 7694

4412 Purdy Shores

New York

Phone

p +1 (555) 909 7694

Experience Experience

Houston, TX

Manager Claims

Houston, TX

Raynor Group

Houston, TX

Manager Claims

Providing developmental feedback, coaching, and direction on work management
Provide expertise in leading Supervisors and teams in claim management, issue resolution, business segment partnerships and process improvements
Conduct data entry and re-work; analyzes and identifies trends and provides reports as necessary
Coordinate work activities with other supervisors, managers, departments, etc
Working with supervisors to oversee the daily activities of claim operations teams and working to support the processes
Work in collaboration with our business partners to ensure expectations are being met
May oversee work activities of other supervisors

Houston, TX

Manager, Claims

Houston, TX

Price, Pouros and Jacobi

Houston, TX

Manager, Claims

Investigates claim inquiries from account managers, care managers, member service representatives, members and providers
Works closely with senior management in developing short and long-term goals that are strategically aligned with the organization’s focus and vision
Collaborate with internal support teams and management to effectively manage staffing levels, employee morale and process improvement initiatives
Development and maintenance of well-defined processes to enter, adjust, manage and report claims and encounters data
The review of provider contracts and configuration of these contracts within the claims processing system to assure accurate payments to our providers
Attend industry meetings and develop national relationships and a network of industry contacts
Assist in development of annual budget for Claims Department

present

San Francisco, CA

Manager Claims AFS

San Francisco, CA

McDermott LLC

present

San Francisco, CA

Manager Claims AFS

present

Implement productivity improvement measures by coaching staff on any new processes or by making staff aware of their own areas for improvement
Approve leave requests for team members by regularly accessing and updating ESS and MDT and ensure that all leave is managed effectively
COP/ Intermediate and Higher certificates in Insurance Studies
Ensure that sufficient feedback regarding Ombudsman, CEO and Action line complaints are provided via e-mail to the Customer Service Department within the timelines as stipulated by the particular department
Build and maintain relationships with Absa Advisers and independent brokers by visiting at least 3 brokers per month and making courtesy calls to those advisers/brokers who are not visited
Ensure the implementation of cost effective claims procurement methods by communicating, explaining and constantly monitoring the directives as set out by the Procurement department
Computer literate (MS Office)

Education Education

Bachelor’s Degree in Related Field

California State University, Northridge

Bachelor’s Degree in Related Field

Skills Skills

Proactively plans for daily priorities as well as responds to new priorities within the organization and opportunities assigned from upper management
Responsible for compiling and submitting daily, weekly and monthly departmental reports to management
Acts as a technical expert in handling complaints and other escalated issues from internal and external customers
Supports claims performance improvement via participation in special claims initiatives
Pega experience
Advanced Excel
Call center sits in Addison, minutes from Belt Line and easy access to the Dallas North Tollway and George Bush
We maintain a fun, family culture, focused on community, employee well-being, and employee growth and recognition
The average agent tenure is over 6 years
All of our employees are eligible for generous incentive plans

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Team Manager Claims Resume Examples & Samples

Assist the Business Unit Manager to identify and implement strategies and improvements that assist in achievement of claims targets
Provide expertise and assistance in managing the working relationship with support areas to drive the analysis of root causes, the results of quality audits, solution design and process improvement
Act as an escalation point on Claims Administration issues and any related complaints
Manage incoming work volumes, rosters and administration systems, functions and workflow management to ensure the service proposition offered to AMP customers is consistently achieved
Previous experience in leading people across financial services and driving a collaborative, high performance culture
Relevant experience in customer resolution and complaints management
Demonstrated experience with Superannuation death claims
Ability to manage high volumes and lead a team to work effectively under pressure and/or through a significant change event
Strong ability to coach, motivate and influence team members in a fast paced environment and/or through period of change
Demonstrated problem solving and decision making skills
Evidence of being 'process driven' and having high attention to detail

Manager Claims AFS Resume Examples & Samples

Achieve client satisfaction through effective leadership of staff i.e. through the formulation and implementation of initiatives to improve and enhance staff morale, motivation, and level of skill, professionalism, work and commitment to service delivery
Explain targets to all claims staff and take accountability for the monitoring and achievement of performance objectives in the department in terms of employee satisfaction, customer experience, cost performance, return on investments, and risk, compliance and governance requirements by creating quarterly and monthly plans in order to ensure delivery for the year
Allocate duties to team members in order to achieve operational targets including prioritisation and work scheduled in consultation with Team Leaders
Obtain a thorough understanding of the business unit's strategy and explain it to team members in such a way that they understand the contribution they have to make
Ensure excellent client service (e.g. ensure CSI targets are above 80%) by constantly reinforcing service excellence principals i.e. to answer a telephone within 3 rings, with all staff
Ensure that all actions taken by staff relating to the claims process are executed within the agreed timelines as stipulated in various service level agreements by performing quarterly quality audits on each claims technician’s portfolio of claims
Implement and monitor all service initiatives by obtaining the 'buy in' of all the relevant stakeholders’ i.e. all levels of staff, that the particular initiative would improve the service delivery to the internal and external customer base
Assist with and manage all queries escalated by staff, brokers, clients or service providers to ensure timeous and amicable resolution of the query by diarizing and following up on progress until final resolution. Complaints, including Ombudsman, CEO and Action line complaints received pertaining to the relevant C&I Claims department by diarising and following up on progress and ensure that adequate action is taken to address the complaint
Ensure that sufficient feedback regarding Ombudsman, CEO and Action line complaints are provided via e-mail to the Customer Service Department within the timelines as stipulated by the particular department
Build and maintain relationships with Absa Advisers and independent brokers by visiting at least 3 brokers per month and making courtesy calls to those advisers/brokers who are not visited
Manage and contain claim spend by ensuring efficient cost control procedures are followed at all times. The main bottom line drivers for efficient cost control must be closely monitored and this can be achieved by constantly reviewing the claims paid, accurate estimates, salvage management, recoveries, car hire expenditure and release fee management
Ensure the implementation of cost effective claims procurement methods by communicating, explaining and constantly monitoring the directives as set out by the Procurement department
Achieve effective cost control and monitor the overall claim cost per section and average claims cost per product per branch by analysing all available MI and drafting action plans to address possible shortcomings
Control and monitor salvage recovery process (including payment of release fees) by keeping an accurate salvage register, outstanding salvage statement, salvage bordereau's and a salvage money receipted register to ensure that all recoveries are maximised and that all monies due are recovered and processed on the policy administration system (currently Asti) within the month of receipt
Control and monitor the flow of all claims with a third party liability/recovery aspect to the Recoveries department on a regular basis by keeping an accurate record of all claims submitted to Recoveries and comparing the register to the number of claims registered indicating a third party involvement by means of a loss cause code (ACCDTPTL and ACCDTPPL)
Rigorously monitor controllable expenditure against approved budgets by carefully reviewing the management expenses report, continuously identify areas for improved efficiency and reduced cost and put measures in place to address variances
Implement productivity improvement measures by coaching staff on any new processes or by making staff aware of their own areas for improvement
Drive operational business targets by constantly setting and reviewing relevant and accurate targets in order to improve cost and profitability and to motivate and inspire claims staff to improve on achievements
Pro-actively identify areas of potential fraud and combat fraud by enforcing strict compliance to mandates, set procedures, processes, philosophies and Company rules and regulations
Ensure that staff adheres to the claims processes, procedures and controls as defined in service initiatives, services level agreements, claims procedure manual and claims management bulletins by doing quarterly quality audits. The outcome of these audits and an action plan to address shortcomings (if necessary) must be discussed with the particular employee in a performance tracking session and must be recorded the particular monthly claims head office report
Manage effective cost control of claims estimates and settlements by adhering to claims settling authority and the raising of correct estimates and processing of accurate claim settlements/payments. Evidence of estimate or payment approval (signature and date) must be kept on file
Manage and control a proper segregation of duties at claim payment authorisation by ensuring that the correct level is authorising claim payments in accordance with their delegated claims settlement authority as set by head office
Ensure that all staff adheres to the turnaround times as documented in various service level agreements by reviewing the recorded turnaround times and compare same to the SLA's. In the event that the turnaround time is not in line with the SLA's, corrective procedures and action plans must be agreed on, implemented and controlled in order to ensure improvement
Ensure that the data entered on the policy administration system (currently Asti) is of the highest quality by verifying the data input during the quarterly quality audits and at estimate or payment authorisation stage
Analyse all available MI and monitor the effective actioning of all relevant claims listings (system generated) and their consequences (e.g. claims age analysis) by the claims staff
Analyses of required MI must be included in the Monthly Claims report to be submitted on the 15th of every month to the branch manager and Head Office
Claims, Quality audit results, ASTI listings analyses and action plans, PD steps relevant for the month, Result of estimate revision exercise, Information regarding personal development of staff, Broker relationship building efforts, Outstanding work stats, Salvage management information, Recoveries statement and Ombudsman complaints
Manage and control the claim rejection policy by keeping a by month register of all rejected claims; all rejection letters must be co-signed by the claims manager and copies of same kept in an arch lever file. Contested rejections must be forwarded to Claims Resolution Committee for arbitration
Outstanding work stats must be controlled and monitored on a weekly basis by obtaining stats from the relevant team leaders in a prescribed format and analysing those in order to determine where focus is lacking. It is required to perform random spot checks on the numbers submitted to ensure quality and accuracy thereof
By utilising the STL 488 (approved claims per facilitator) a trend analysis should be developed to identify over/under usage of contractors and appropriate action and reporting must be done in the monthly claims report
Ensure that BEE targets are met by cross utilisation of only preferred contractors to a 80% average
Assist the Procurement department with obtaining signatures and the collation of the required documentation for service providers to be added to the preferred panel by liaising with the service providers on a regular basis
Mitigate risk of long outstanding claims by reviewing the claims team leader's summary of STL461 (Claims Age analysis) and ensure action plans are agreed, implemented and completed, where applicable. Keep evidence of review for audit purposes
Identify and report to underwriting via e-mail risk areas and actions to eliminate potential future losses (e.g. Identification of hazards, inadequate housekeeping)
Create a motivated work environment where employees want to work hard to achieve service excellance by providing regular feedback on their performance and by making sure that the employees' efforts are recognised
Develop a high performing team by embedding performance development (PD) and by having regular informal coaching conversations with all staff Conduct performance development discussions with the claim team leaders in accordance with the PD cycle as published by HR
Ensure that the claims team leaders have performance development discussions with their respective team members in accordance with the PD cycle by obtaining and documenting the results and updating MDT when required
Determine and analyse training needs for the claims team and ensure that all agreed development/training interventions are scheduled, approved and executed by keeping a detailed training log and submitting the information in the monthly claims report
Ensure that all claims staff have a duly signed PD plan by documenting the responsibilities pertaining to the position and the agreed training/development needs and updating the PD plan after every performance development discussion. The signed PD plan must be kept on the individual staff files
Sustain an adequate level of trained and competent claims staff at all times by interviewing and recruiting team members with the support from the HR Business partner
Approve leave requests for team members by regularly accessing and updating ESS and MDT and ensure that all leave is managed effectively
When required, initiate the disciplinary process together with HR consultants taking into consideration the ER processes
Act as first level escalation point for all grievances raised in the department
Ensure that any poor performance is addressed through the formal Absa performance improvement programmes and that continued poor performance is appropriately dealt with
Execute EOS action items identified by the HR Operations management team and report on results of the action to the branch manager
Diploma in Short Term Insurance
COP/ Intermediate and Higher certificates in Insurance Studies
Minimum 5 years’ experience in short and long term insurance
Minimum 3 years at claims supervisory level
Experience in claims cost control principles
Excellent verbal skills
Thorough understanding of claims handling process

Senior Manager, Claims & Risks Resume Examples & Samples

Risk management for the operations of New Avon in the United States, Canada and Puerto Rico
Assist in monitoring, managing and recommending settlements of Workers' Comp, General Liability and Business Auto claims
Oversee the Third Party Administrator's activities to ensure claims are settled in a timely manner at optimal cost
Determine/understand how self-funded casualty claims impact the company's P&L, B/S, Cash and Liquidity positions
Oversee actuarial projections and claims reviews to ensure the adequacy of balance sheet reserves for self-insurance
Identify and assess risk hazards, including best practices for reducing workplace risks
Coordinate the gathering of data for renewals
Develop pro forma insurance budgets and forecasts
Purchase insurance policies protecting corporation from risks
Develop and implement risk management strategies for New Avon based on past approaches/industry best practices
Require annual stewardship reporting of key insurance carrier and broker client service teams
Knowledge of the insurance industry is mandatory
Has at least 10 years of claims management experience with a focus on workers compensation, and some understanding of insurance program design
Self-motivated with the ability to understand nuances of risk management and insurance
Capable of keeping pace in a fast moving and changing company environment
Strong project management skills, capable of multi-tasking and setting priorities
Possesses good knowledge of company risk issues and third party provider solutions
Team player â€“ works well with others in accomplishing risk management objectives
Strong written and verbal language skills
Proficient in Excel, Word, PowerPoint and the Internet
Experience in data modeling helpful

Manager, Claims Resume Examples & Samples

Responsible for directing the planning, design, development, implementation and evaluation of policies and procedures that assure accurate, timely claims and encounter processing and provider inquiries (written or verbal)
Assure timely and accurate processing of Medicare claims and encounters, and respond to provider telephone calls, written inquiries, and appeals
The compilation of all information and documents required for claims and encounter processing and related inquiries to assure compliance with all applicable rules, regulations, and external and internal policies and procedures
The review of provider contracts and configuration of these contracts within the claims processing system to assure accurate payments to our providers
Collaboration and communication with other SHP departments on claims and encounter issues, related projects and inter-departmental operations issues
Development and maintenance of well-defined processes to enter, adjust, manage and report claims and encounters data
Preparation and timely submission of management and regulatory reports
Generation of configuration requests to assure accurate, timely administration of providers claims and processing and reporting of encounters
Maintain a full comprehensive understanding of the covered benefits, coding and reimbursement policies and contracts
Production and submission of reports as required
Analyze, track and trend claims and encounters data; identify any potential service or systems issues;implement interventions, and determine success of intervention
BA/BS degree preferred with at least five (5) years of relevant professional experience, and the following OR any combination of education and experience which would provide an equivalent background
Minimum of 3 years of managerial experience at the department manager level
Minimum of 5 years of Medicare/Medicaid claims experience that demonstrates progressive growth within claims operations
Extensive knowledge of claims policies and procedures, including industry standards from Medicaid, CMS, and CCI Edits
Excellent oral and writing skills
Highly developed quantitative and qualitative analytical skills
Highly developed project management skills

Manager, Claims Cypress Resume Examples & Samples

Manages and develops direct reports who include Team Leaders and front-line associates. Directs work assignments, measures results and initiates personnel actions as required for assigned claims unit
Manages process improvement initiatives, seeking root cause and developing appropriate corrective action
Applies a comprehensive knowledge of claims and provider contracts to the completion of assignments. Has knowledge of all products and all types of claims
May make recommendations on matters of policy and approve changes in area of expertise

Manager, Claims Edi-so Cal Resume Examples & Samples

Work closely on a daily basis with our encounter data submissions team
Responsible for managing day-to-day activities
Prioritizing workloads
Making work assignments and KPI metric reporting
Responsible for the process unit that handles risk adjustment encounter retractions
6+ years of claims experience (including 837 I & P)
3+ years of Risk Adjustment encounter data submissions
Proven proficiency in CPT4, HCPCS, ICD9/10 and NUBC code sets
Proficient in MS Office Suite including Word, Excel, Work and PowerPoint
3+ years of experience managing staff
Compliance or process design experience

Manager Claims Resume Examples & Samples

Initiating and implementing process improvements
Managing inventory, turnaround times, quality and productivity for the department
Participating in meetings (remotely)
Overseeing national projects, such as process reengineering, quality/productivity initiatives, etc
Work in collaboration with our business partners to ensure expectations are being met
Strive to ensure processes are continually assessed and improved wherever possible
Providing input on company-wide tactical issues
Producing regular management reports
Coordinate work activities with other supervisors, managers, departments, etc
Identify and resolve operational problems using defined processes, expertise and judgment
Provide coaching and feedback to team members, including formal corrective action
Conduct annual performance reviews for team members
Manages and is accountable for professional employees and/or supervisors
Strong communication, public speaking and presentation skills required

Manager, Claims Resume Examples & Samples

Plans, organizes, staffs, leads and controls activities pertaining to the Claims process to include: projects and capital and human resources budgets; interviewing, selecting, and training supervisors; monitoring and appraising performance of direct reports to hold them accountable for end results including human resource management; coaching and motivating direct reports; administering disciplinary action as needed; administering compensation to direct reports; ensuring that Claims complies with affirmative action guidelines
Demonstrates competency as a process owner by engaging with business partners in an effort to create efficiencies. Actively participates in training and experience opportunities to further develop Lean acumen. Ensures that all team members are actively engaged in training and practicing continuous process improvement
Ensures all daily activities support the Division efforts to meet or exceed corporate policies, procedures, and/or directives. Ensures all new legislation, mandates and legal requirements are analyzed and information is disseminated to the appropriate functional areas for review and implementation. Identifies areas of noncompliance, developing procedures to modify and/or enhance existing processes and initiates corrective action
Organizes, monitors, measures and controls department workflow, establishes and maintains quality and time service standards assuring timely service to internal and external customers
Develops and maintains an engaged and accountable workforce
Develops, implements, directs and monitors adherence to department policies that support a comfortable and productive work area as well as to contribute to customer loyalty and high policyowner persistency
Establishes and maintains effective internal and external working relationships within the division and throughout the Companies to ensure support and attainment of Division and Corporate goals and objectives and ensures effectiveness of service delivery. Maintains effective working relationships with key stakeholders to identify business opportunities and ensures support and attainment of area and Corporate goals and objectives. Functions within a dynamic and market-driven insurance environment with complex products and extremely demanding service requirements
Maintains current knowledge of the regulatory environment, innovations in technology, claims processes, and may include marketing techniques to retain existing business and exploit new opportunities
Leads and participates in project activities initiated to enhance customer satisfaction, corporate profitability, productivity and/or quality. Researches and analyzes trends and changes across service and new business, based on customer feedback, as well as the overall insurance industry and develops related plans to improve service delivery and products
May participate in the development of products and marketing strategies by serving on product development teams to establish strategic direction and develops business plans to ensure product line growth and profitability objectives
Assesses, monitors and coordinates training needs and resources to contribute to the overall development of Division Associates
Maintains a current knowledge of services, claims and new business trends and a proactive posture in the insurance and service industries. Remains current on legislative changes impacting the insurance industry and the servicing of clients
Develops and supports claims activities for all products sold and administered by the Companies
Assists in the coordination and monitoring of daily claims activities including quality and quantity of work and corrects minor workflow problems
This position requires 1-33% travel, which may include flying and/or driving and some over night stays
This position requires you to lift, move, or carry heavy objects
Effective management skills, strong leadership, analytical, decision-making, communication and human relations skills
Proven effectiveness in managing in a service environment
Ability to effectively plan, organize and manage multiple projects and activities
Sound and independent judgement and the ability to think and conceptualize beyond existing barriers, methods and practices
Seasoned project management experience and thorough project management methodologies and tools
Ability to work effectively in a fast-paced dynamic environment
Understanding of corporate policies, philosophies and objectives
Seasoned insurance background with a thorough understanding of life, health, disability, LTC, annuity products, agency systems and supplemental distribution sales
Creativity and resilience
Knowledge of business processing functions including systems technology, and related federal and state regulations
Personal computer operation and skills in various software applications including word processing, spreadsheet, electronic mail and presentation
5-7 years claims management experience
May require government security clearance
May travel up to 10% of work period

Manager Claims Resume Examples & Samples

Provide expertise or general claims support to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims
Conduct data entry and re-work; analyzes and identifies trends and provides reports as necessary
Working with supervisors to oversee the daily activities of claim operations teams and working to support the processes
Assisting the service center organization in achieving operational objectives
Effective verbal and written communication
Ability to coach and develop team into leaders
Ability to influence and mentor mentors

Manager Claims Resume Examples & Samples

Oversee daily operations of multiple Supervisors and multiple claims teams across business functions
Manage day to day operations, supervisor leadership (internal and external to organization) and accountability for performance results including inventory management, quality and production performance
Provide expertise in leading Supervisors and teams in claim management, issue resolution, business segment partnerships and process improvements
Lead and partner on claim process initiatives and support other business projects
Support culture and employee engagement activities and promote employee development
Participates with other Claim leaders, offers input, develops positive relationships

Manager Claims Resume Examples & Samples

Sets team direction, resolves problems and provides guidance to members of own team
May oversee work activities of other supervisors
Influences or provides input to forecasting and planning activities
Product, service or process decisions are most likely to impact multiple groups of employees and/or customers (internal or external)

Manager, Claims Resume Examples & Samples

Performs all duties and responsibilities in support of field services and operations. Supports the Corporate Objectives, including: "If you are not serving the Guest, serve someone who is."
Lead the work activities of our Risk Management department. Manage the team that handles our general liability, workers’ compensation and property claims
Deliver on our brand promise by leading our department’s hospitality program. Our hospitality program is focused on resolving general liability and workers’ compensation claims with a high level of service and care—with a view toward providing “solutions management” rather than “risk management.”
Work closely with our Third Party Administrator (TPA) to help ensure effective program administration while keeping costs in-line with budget
Oversee the management of our claims data base to help ensure accurate and timely tracking of data/reporting
Perform monthly financial reporting
Develop, measure and report on internal team and TPA results/productivity
Oversee the Company’s insurance certificate program
Build the department’s annual budget and goals and regularly monitor and report on the department’s performance
Partner with the Safety Manager and other relevant Company departments to identify initiatives to reduce the number of incidents that might result in claims and to draft or modify policies to achieve such reductions
Work with the Company’s Internal Audit and Legal departments to monitor and report on compliance with the Company’s Kid Check policy
Bachelor or Master's degree in Business, Finance, or another quantitative subject area
5+ years of experience in Risk Management
Entertainment, restaurant or retail sector experiencerequired
Working knowledge of concepts, practices, and procedures for claims management, working with self-insurance, and insurance carriers and brokers
Significant experience managing people, preferably in the claims handling area
Strong background in using Excel, RMIS, and MS based software
Excellent customer service skills with the ability to quickly build relationships

Manager, Claims Administration Resume Examples & Samples

Plans, schedules and supervises the work activities of personnel in reviewing, analyzing, investigating, negotiating and settling claims in compliance with established standards and expectations
Reviews and approves, within assigned authority limits, claim expenses and settlements that exceed the claim adjuster’s granted authority; appropriately refers claim expenses and settlements that exceed personal authority limits for approval
Monitors and evaluates reserves for claims ensures that they are adequate and that reserve adjustments are made, when necessary, consistent with established time frames
Conducts regular reviews of pending and closed files to determine whether claims are processed appropriately; identifies areas for improvement and discusses individual training and development needs as necessary
Prepares monthly reports on quality control, pending and closed file reviews and reserve activity to track and communicate unit performance relating to production, opportunity areas and significant achievements
Identifies and drives ongoing improvement to policies and procedures
Processes claims during periods of high pending volumes and/or staffing shortages
Maintains awareness of existing and proposed legislation, court decisions and emerging trends in claims litigation to monitor the company's compliance with the Unfair Claims Practices Act and to recommend process and/or procedure changes
Reviews contracts for insurance coverage, indemnification requirements, etc
May participate in corporate initiatives such as kaizen events
Responsible for claims area Sarbanes-Oxley compliance
Selects and monitors the performance of external vendors
Assists Director of Risk Management with various projects
10% domestic travel
Bachelor’s degree in business, finance or related area. Advanced degree preferred
5+ years claims industry experience in GL/PL, completed operations, subro. and auto liability claims
3+ years management experience
Industry designation, such as CPCU, AIC, ARM, SCLA, CRIS desirable
Strong proficiency with technology: Stars Enterprise, MS Office, Metaviewer, etc
Ability to communicate in a concise and clear manner

Senior Manager Claims Resume Examples & Samples

Perform oversight for all ARMS clients on a national level, including identifying subrogation, salvage, and subsequent injury fund recoveries
Provide technical expertise in managing commercial auto claims (including fleet and rental exposures) on a nationwide basis
Create, maintain, analyze, and publish various periodic management reports as needed
Timely revise Consolidated Claim Procedures for recoveries as needed
Timely preform claim file reviews of all staff within the ARMS department
Initiate, TRAC TPA claim handling oversight and production data
Maintain manager-level oversight diary on all large claim files within the ARMS department
Negotiate large claim file settlements as needed
Work with members of the management team within the Claims Service Department to train and support the other functions within the department
Maintain necessary information security in accordance with TMM information security policies
Continually monitor legal developments, analyze them, and implement any changes necessary to react to them
Performing special projects and other duties as may be assigned
Five years claims adjusting experience required, multiple lines of claims preferred
Five years minimum claims supervision experience required
Demonstrated leadership in managing a large claims team with national exposures
Ability to work with line managers to achieve necessary results
Ability to create quality management reports using combinations of WORD, EXCEL, and PowerPoint
Must be able to work effectively with limited supervision

Manager Claims Telecommute Resume Examples & Samples

Oversee daily operations of multiple levels of staff and multiple functions across one or more business units
Provide expertise or general claims support to teams in reviewing, researching, investigating, processing and adjusting claims
Authorize the appropriate payment or refers claims to investigators for further review
3+ years supervisory/managerial experience in claims adjudication or customer service
2+ years managing relationships with clients and/or vendors
2+ years managing budgets, process improvement and quality assurance
3 + years of demonstrated experience in leading and managing people
Intermediate Microsoft Office skills Word to create documents, and performance management, with Excel to create Pivot Tables; PowerPoint to create presentations
Understanding of claims processing systems
Understanding of Medicare and Medicaid Regulations
2+ years of experience developing presentations to include charting
Senior Level Supervisory/Managerial experience in medical claims

Manager, Claims Resume Examples & Samples

Proactively plans for daily priorities as well as responds to new priorities within the organization and opportunities assigned from upper management
Supports claims performance improvement via participation in special claims initiatives
Participates in and support the development of strategies to meet business needs

Manager Claims Resume Examples & Samples

Ensure timely processing of claims as required by the Medicaid Contract with the State
Provide customer satisfaction by promptly resolving provider claim issues
Submit timely and accurate reports to MDCH and OFIS. Maintain passing levels for site visit criteria
Interact with internal departments to achieve the goals and objective of the Plan
Review performance of staff; counsel, train, and assist staff as required
Bachelor's Degree in Business or related discipline
4-plus years of claims processing experience
Previous supervisory experience
Previous managed healthcare experience; preferably with Medicaid
Working knowledge of DCH, OFIS and HCFA requirements

Team Manager, Claims Resume Examples & Samples

Develop, with assistance, a flexible, transactional-based Quality program to be rolled-out in stages as new Claims workflow system is implemented
Plan, design and recommend business processes to support quality assurance activities
Implement recommended QA solutions as they are approved
Develop and maintain quality assurance documentation for projects and tasks to include quality metrics, objective and subject evidence to verify compliance to standards and applicable quality plans
Participate in special projects, external audits and process improvements in support of quality assurance initiatives
Develop processes to achieve sound risk management
Ensure that the QA program is applied consistently, that results of the program are accurate and consistent and that daily/weekly and monthly production goals are met
Provide reporting and analysis on process performance, provide monthly feedback and analysis as issues or opportunities are identified within LTC Claims processes
Monitor capacity and performance metrics
Participate in weekly/ monthly/ quarterly forums with other LTC Claims leaders to ensure appropriate feedback loops and process improvement opportunities are discussed and implemented
Meet functional and processing goals
Work closely with project teams and other Claims leaders to satisfy customers and to ensure efficient monitoring of workflows
Drive performance management through coaching, motivating team members, providing feedback and direction against stated goals, writing and delivering performance evaluations and taking corrective action as necessary to drive individual and/or team performance
Train team in system, claims and departmental procedures. Develop and coordinate/conduct individual and group training sessions as needed
Recruit, mentor and develop team members
College degree or equivalent experience
Knowledge of Quality Assurance concepts
Demonstrated leadership skills, ability to motivate teams
Excellent internal and external customer service skills including patience, tactfulness, ability to remain calm and composed under pressure, effective listening skills and professionalism
Excellent communication, team building, and interpersonal skills
Ability to effectively plan, prioritize, and deliver multiple projects/assignments in a timely manner
Demonstrated change agent - must be able to understand, embrace, and make change happen
Strong proficiency in Word, Excel, Outlook and PowerPoint
Superior attention to detail
1-3 years of claims team management experience
Experience creating and implementing new quality programs which measure consistency and accuracy of tasks
Genworth LTC Claims experience in quality assurance
Strong understanding of business process flow along with strong analytical, problem solving and judgment skills

Manager, Claims Resume Examples & Samples

Resolve processing/system issues within assigned department
Prioritize work volumes on a daily basis
Oversee status of production in assigned department to ensure goals are being met
Analyze impact of new implementations on assigned department and reallocate staff duties as necessary
Assist in development of annual budget for Claims Department
Drives change initiatives to address future-oriented business needs
Identifies process and infrastructures needed to support change and considers broad range of internal/external factors when making decisions
Bachelor’s degree in related field or equivalent experience
Medicaid/Medicare claims operation experience, 2+ years experience as a manager, Claims inventory management, Health Plan escalation point
3+ years experience in a claims processing role, preferably in a managed care environment
Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff
Pega experience
Advanced Excel

Manager, Claims Resume Examples & Samples

Works closely with senior management in developing short and long-term goals that are strategically aligned with the organization’s focus and vision
Provides leadership to Call Center team by organizing, developing, controlling and coordinating the day-to-day activities for both exempt and non-exempt employees to ensure the delivery of efficient and effective levels of service
Actively participates in the recruiting, hiring, orientation, training, assigning, coaching, and counseling processes. Responsible for attracting and retaining talent. Partners to plan initiatives, communicates job expectations, monitors results, appraises and reviews job performance, and determines compensation actions. Makes authoritative recommendations in such matters of discipline and terminations within area(s) of responsibility
Establishes standards for effective job performance and evaluates area(s) of responsibility according to such standards. Ensures employee accountability in meeting/exceeding such standards
Responsible for the development and maintenance of an effective organization for area(s) of responsibility, including: a) efficient work flow patterns; b) established performance standards; c) effective delineation of duties and responsibilities; d) suitable staffing levels; e) appropriate supervision; and f) systems for timely communication of pertinent information
Responsible for the development, implementation, documentation, and monitoring of direct report and/or indirect associate performance, within span of control, including attendance, schedule adherence, quality, customer experience, and call center metrics. Ensures compliance with regulatory standards and client contract SLA’s and expectations
Fosters the development and learning of supervisors. Communicates clearly defined and concise expectations, giving appropriate feedback, coaching, and developmental opportunities. Develop and maintain a culture of Learning, Performance and Engagement
Creates and nurtures an ongoing relationship with the client account executives to ensure their needs are met and contractual obligations are being fulfilled
Participates on committees and in programs for safety, disaster recovery, employee engagement, and employee well-being. Ensures the development of specific plans for inclusion in these programs
Develops and cultivates a strong working relationship with other functional areas across the business. Aligns to understand their goals and objectives while balancing the priorities of all parties involved in order to meet the business objectives
Receives and investigates all complaints concerning area(s) of responsibility and its personnel; determines veracity of such and (as necessary) takes corrective or disciplinary action and/or prepares reply
Remains abreast of developments in the contact center/customer experience field, by pursuing a program of self-development, participating in professional organizations, interacting with peers, reviewing pertinent literature, etc. Incorporates advancements when practical and cost effective
Collaborate with internal support teams and management to effectively manage staffing levels, employee morale and process improvement initiatives
Reviews daily/weekly/monthly reports and analysis for area of responsibility and ensures key performance indicators are being met. May require additional analysis or creation of reports. Takes corrective action as necessary
Three to five years of progressive leadership of large numbers of associates and leaders
Coaching and development of Supervisors and Associates
Must possess a passion for people
Advanced MS Office Skills
Must possess strong interpersonal skills, promoting employee growth and engagement
Must possess high degree of professional and emotional maturity. Must be a self-starter who is proactive, confident but humble, results and team oriented
Must be able to adapt and lead others through fast-paced change

Assistant Manager Claims Resume Examples & Samples

Oversees internal quality review process and reports monthly
Assures compliance with client internal controls, audit requirements and service agreement requirements
Establishes business plan with goals and objectives for assigned clients
Ensures claims management policies and procedures are followed to assure meeting service standards, state statutes/regulation, disability plan document, industry best practices and client service requirements
Establishes and maintains client contacts
Assists with interviews, hires and establishes colleague performance development plans; conducts colleague performance discussions

Manager, Claims Management Resume Examples & Samples

Managing daily department staff and activities through regular meetings, communications to staff, and review of operational reports
Mentoring and developing team members for career progression and performance improvement
Proactively identifying and leading process improvement initiatives using Lean tools and concepts
Interacting directly with clients to address and resolve escalated issues
Developing, implementing, and monitoring operational reports to ensure that service targets and client expectations for quality, speed, and accuracy are met or exceeded
Participating in industry associations/networks for the purpose of advocating for clients, maintaining industry expertise, and increasing service performance/value
Reviewing system edits and capabilities to ensure alignment and compliance with payer policy
Working with the Training, Quality, and Documentation team to develop, communicate, and maintain training programs, quality control policies, and standard operating procedures
Working with the Workforce Optimization team to develop work forecasts, productivity plans, and staffing models
Conducting education sessions for groups of client staff on payer policy and service capabilities/value
Providing sales support through expertise and analysis of new business opportunities
Evaluating and proposing promotions and salary increases for department staff
Administering corrective action, up to and including termination of employment
Interviewing, hiring, and onboarding new team members
Project work as assigned by leadership
Proficiency with MS Office Suite, including Excel, Visio, Outlook, and PowerPoint
Proficiency with PC and Microsoft Operating Systems
3+ years’ experience in operations/staff management
Experience with Pharmacy workflows, Medicare Part B policy, medical claims processing, and/or claims denial/audit management is preferred
Experience managing department expenses to an operational budget is preferred
Experience with Lean process improvement tools and concepts is preferred
Experience and success working in a matrixed environment, which requires organizational savvy and collaboration with functional leaders to accomplished shared goals
Strong writing, communication, and customer service skills
Strong public-speaking skills
Proven ability to manage multiple projects and priorities
Highly motivated, self-directed, and results driven

Manager, Claims Resume Examples & Samples

Monitors inventory, audits, and action plans
Develops department objectives and standards
Reports on claims department activities to claims director using system database information
Guides and educates staff in claims policy and procedures
Investigates claim inquiries from account managers, care managers, member service representatives, members and providers
Apply Beacon Health Options policies and procedures consistently while maintaining confidentiality and ethical professional standards.Maintain individual productivity and performance standards.Meet Departmental expectations for accuracy.Adhere to the components of the Compliance Program including HIPAA guidelines.Ensure that job tasks are performed in a legal and ethical manner.Actively assess work area for non-compliance issues and notify supervisor or calls Ethics Hotline. Adhere to compliance training requirements and understand that training is required codition of employment. Complete tasks accurately and within required timeframes
Strong customer service orientation, excellent written and verbal communication skills required
Must have knowledge and experience using management information systems, Microsoft Word, Excel applications

IT Development Manager, Claims Resume Examples & Samples

Day to day team leadership and EDI resource development
Liaison between key internal and external stakeholders and the EDI team
Responsible for development team deliverables, in particular system use cases, design documents, coding and unit testing
Create and integrate maps and processes within EDI systems/technology stack
Participate in and provide analytical support for the design and implementation of new systems
Serve as subject matter expert for implementation and integration of EDI transactions
Oversee operational support for EDI platform and applications, including issue resolution
Manage EDI-related IT development and production support responsibilities, which include production monitoring, file maintenance, ad hoc reporting, and consultation with internal and external users
Perform team administrative duties including status reporting, team development, self/peer/project assessments
Develop analytical skills and increases applications knowledge within the team and lead efforts to develop department core competencies, execute cross training, and implement succession plan
Carry out personnel management activities including performance management and career development
Manage and mentor the development and support teams
Ensure appropriate level of support for the ongoing performance of EDI processes and applications
Maintain a leadership role in setting service direction and ensure standards and policies are maintained and compatible with BSC standards
Collaborate with all Business and IT stake holders across the organization to improve departmental and organizational performance by developing benchmark measures to evaluate productivity and service quality
HIPAA ASC X12 transaction sets for healthcare (837, 835, 277CA, 999 & TA1)
HIPAA 5010
HIPAA security policies and procedures
IBM Sterling, ESB(WMB/WTX) & MQFT
Facets Trizetto HIPAA Gateway(THG) & XC
Edifecs
Web services integration
Leadership and project management, including managing/developing staff, promoting teamwork and encouraging innovative ideas
Working with business stakeholders to define application strategies, roadmaps and funding requests
Strategic thinking and planning with operational execution excellence
Software developer in a complex technical environment with multiple platform components and integration points
Excellent communication skills and strong ability to work independently and effectively with business and technical resources
3+ years managing software development resources
The candidate should have experience in successfully leading technical teams to deliver design documents, code and unit test results as per approved architecture solution and requirement documents
Experience in working with on-site and off-shore resources, and a working knowledge of Enterprise Application Integration & Service-Oriented Architecture

Manager, Claims Resume Examples & Samples

Plans, organizes, staffs, leads and controls activities pertaining to the Claims Support processes to include: projects and capital and human resources budgets; interviewing, selecting, and training supervisors; monitoring and appraising performance of direct reports to hold them accountable for end results including human resource management; coaching and motivating direct reports; administering disciplinary action as needed; administering compensation to direct reports; ensuring that Claims complies with affirmative action guidelines
Demonstrates competency as a process owner by engaging with business partners in an effort to create efficiencies. Actively participates in training and experience opportunities to further develop operational Excellence. Ensures that all team members are actively engaged in training and practicing continuous process improvement
Ensures all daily activities support the Division efforts to meet or exceed corporate policies, procedures, and/or directives. Ensures all new legislation, mandates and legal requirements are analyzed and information is disseminated to the appropriate functional areas for review and implementation. Indentifies areas of noncompliance, developing procedures to modify and/or enhance existing processes and initiates corrective action
Effective working relationship with key stakeholders, Group Insurance Brokers, Group Sales Offices, Employers, and External Vendors to create innovative solutions for the customers and to work collaboratively to accomplish resolution for business situations
Manages and monitors ongoing contractual and working relationships with external vendors to meet business requirements
Proven ability to effectively lead a team that provides value add services to both internal and external customers
Seasoned experience with appeals, disability claims, claims management and support services
Strong medical background
Proven collaboration and communication skills
Seasoned insurance background with a thorough understanding of life, health, pension, annuity products, agency systems and suplemental distribution sales

Manager, Claims Resume Examples & Samples

Support, manage and coordinate day to day activities of Claims Department by providing strong leadership to department supervisors and staff through 1 on 1 communication, team meetings, individual coaching, teaching and evaluating. Be available to staff on a daily basis to answer questions and provide support and guidance
Responsible for human resource planning through staff selection, coaching, performance reviews and termination
Establish and implement effective unit performance goals and measures that are aligned with business objectives. Provides ongoing monitoring and reporting of measurements
Independently investigates complex claims and coverage issues bringing to resolution in a timely manner
Works closely with other departments within organization on shared issues to effect positive change
Continually search for and implement methods to improve overall operational efficiencies and processes to better manage total claims costs, and deliver superior customer service
Provide interpretation of benefits, delegated contracts and provider contracts in matters regarding claim functions
Promote compliance with all regulatory standards including CMS, DMHC, DHCS, and HIPAA

Manager Claims Telecommute Resume Examples & Samples

Manage day to day site operations, supervisor leadership (internal and external to organization), and accountability for financial and non - financial results (budgets and actuals)
Conduct data entry and re - work; analyzes and identifies trends and provides reports as necessary
Must be available during regular business hours
Manages and is accountable for professional employees and / or supervisors

Manager, Claims Resume Examples & Samples

Works closely with the Claims management team, regional management team and other departments to resolve specific claims issues and ensures compliance with all health plan requirements and industry regulations
Attends meetings to provide input (i.e. reports trends and assesses the root of the problem), obtains information and disseminates results of these meetings appropriately
Updates and establishes new guidelines and procedures for automation processes using appropriate reference materials
Manages the identification, reporting and coordination of benefits / third party liability cases
Recovers overpayments and underpayments
Reviews provider’s payment appeals, performs negotiation with provider and initiates resolution disputes
Assists with the negotiation of provider settlements
Participates in health plan audits to ensure that all necessary documentation is provided for health plan audits and discusses HCP’s outcomes
Oversees the Retro Review process and works closely with Care Management to align claims payment guidelines for claims authorization
Provides input to CAP (corrective action plan) as needed
Applies appropriate reference tools (e.g. Prospective Review List, Preferred Provider List, CPT and ICD-9 coding books, HCP and IMCS policies and procedures manual)
Maintains and updates the department policies and procedures manual as required
Devises standard forms and letters for department use
Participates in the development and implementation of strategic workgroups (internal and external)
Participates in the continuous maintenance and quality improvement of IMCS core business system
Participates in the preparation process for the annual budget and monitoring of monthly budget year to date
Provides direction, guidance, and training to department supervisors and staff
Assists in the development of departmental and individual goals
Ensures appropriate management of department staff including timely completion of performance appraisals and corrective counseling when necessary
Advanced knowledge of medical terminology, ICD-9 and CPT coding
Proven problem-solving and decision-making skills
Valid California driver’s license

Manager Claims Telecommute Resume Examples & Samples

Experience with medical coding
3+ years of supervisory / managerial experience in claims adjudication or customer service
2+ years of managing relationships with clients and / or vendors
2+ years of managing budgets, process improvement and quality assurance
Senior Level Supervisory / Managerial experience in medical claims

Manager Claims Service Resume Examples & Samples

Computer literate in Windows operating environment
Working knowledge of applicable Microsoft Office applications and business systems
Strong multitasking skill with ability to manage multiple priorities effectively
*Selected candidates will attend and complete the Management Development School program in San Antonio, TX, during their first six months in position.***

Manager, Claims Workforce Management Resume Examples & Samples

Conceptualizes immediate and long-range needs of the SBU with respect to project mission. Must understand business objectives as they relate to project goals
Translates SBU needs into a comprehensive project plan which ensures successful project completion
Negotiates projects objectives and direction with SBU heads, Division Senior Vice Presidents and Managers of such departments as Information Systems, Corporate Research , Actuarial, Underwriting, Claims, Sales, Legal, and Human Resources
May act as the project lead for various departments and divisions to ensure the completion of work in a timely and efficient manner
Prepares periodic written reports for Senior Managers regarding project status and keeps Senior Managers informed of project direction and renegotiates direction as necessary
Makes presentations regarding project direction and recommendations to Senior Managers
Identifies sources and relationships of corporate data and makes recommendations/decisions regarding consolidation and storage of data for access by Senior Managers
Graduate degree in related field or equivalent training required

Manager Claims Services Resume Examples & Samples

Reports to and interacts with lead attorney, Law Services-Litigation
Plans, prepares and manages staffing, budget and equipment requirements
Supervises the response and resolution of claims against SRP in a fair and economic manner while maintaining good customer relations and reflecting SRP's legal responsibilities
Evaluates liability and financial exposure to loss regarding claims asserted or potentially asserted
Establishes proper dollar reserves to reflect SRP exposure and financially manages that exposure
Assists with the handling of claims in litigation in conjunction with attorneys and/or outside counsel; reviews loss reports/prepares investigative material and other legal duties
Acts as liaison in providing insurance carriers or brokers communications regarding settlements, litigation and/or defense of serious claims
Reports to management and to the Board of Directors regarding serious or sensitive claims. Prepares reports on claim volume, type of claim, number of claims paid and reserved. Prepares systematic summary of claims paid and reports same to SRP management and the SRP Board of Directors on a periodic basis

Manager, Claims Resume Examples & Samples

Develops people, including coaching all team members effectively, recognizing and rewarding progress, encouraging and modeling continuous learning and development
Assessing teams’ adjudication skills and elevating expertise to full competency in all required functions and company-approved technologies and tools
Understand the vision of the department and translate it into action and incorporate into the day-to-day operations by ensuring that service and quality objectives are being attained and maintained on a consistent basis
Understanding group dynamics, building strong, productive and cohesive teams, demonstrating collaboration and mutual problem solving, and providing leadership opportunities for team members
Responsible to align sales objectives with operations objectives and corporate objectives of fair claims practices
Collaborate with other leaders, including Insurance Operations Leadership Team (IOLT) to ensure that all functions are fully integrated and are in accordance with the Company's goals and objectives, ensuring that all overarching SLA's are met and/or exceeded
Effectively liaise and negotiate with other business units, including legal and underwriting to resolve and enhance customer service expectations and business deliverables
Plan and control department budget by anticipating future employee requirements, supplies and equipment, and improving department effectiveness while managing expenses whenever possible, including creation and management of capacity models
Monthly and Quarterly reporting of key claims metrics and trending as well as the ability to interpret reporting, and act upon results, to help manage all aspects of Claims
Representing Foresters from a claims perspective during the course of litigation or regulatory hearing; including acting as a witness during such process, and participating in mediations and settlement conferences
Responsible for working closely in conjunction with Reinsurers
Attend industry meetings and develop national relationships and a network of industry contacts
Assess, negotiate and resolve disputed claims based on their merits in a fair and cost effective manner according to state and provincial laws and regulations, and according to Foresters claims philosophy and Manual
Minimum of 7-10 years of claims management experience including individual life and living benefits claims adjudication (principles, methods, systems, processes and standards)
Understanding of insurance medicine, and actuarial principles/methods as they relate to the claims function
Thorough knowledge of the interpretation and application of life claims adjudication, common law, legislation and regulations across Canada and the U.S
Strong people leadership skills with the proven ability to create and lead high performing teams
Change Management, including the ability to work in a new and ambiguous environment where tasks, processes, procedures, and lines of authority are evolving and changing
Financial Industry Products and Services, including a basic knowledge of their characteristics and suitability for different customer needs, keeping current with IOF products and services as partnerships develop and keeping up to date with general trends in the financial industry
Excellent problem solving and analytical skills to identify and report on team's progress, business trends, initiatives, customer and employee issues, including the ability to identify problems in their early stages and solve by analyzing options and developing alternative solutions
College Diploma or University Degree an desired
Insurance designations (i.e. ALHC, FLMI, ACS) an asset
Bilingual French is also an asset