Claim Specialist Resume Samples

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H Johnston

Helen

Johnston

73620 Howe Rapids

Boston

+1 (555) 124 8405

73620 Howe Rapids

Boston

Phone

p +1 (555) 124 8405

Experience Experience

Los Angeles, CA

Claim Specialist

Los Angeles, CA

Walsh, Pfannerstill and Dicki

Los Angeles, CA

Claim Specialist

Act as a subject matter expert on business projects. Assists in managing projects/pilots
At least five years working as a claims scheduler, mainly on the side of a contractor but consultant/client-side exposure is an advantage
Advanced knowledge of state compliance regulations and interpretation of state statues
Identify claim process and procedural gaps. Research and implement solutions that are in compliance with state insurance laws. Present recommended changes to senior claims leadership
An effective communicator, oral and written
Highly conversant with delay impact analysis methodologies and with window analysis processes
This is not a management position; this is a position for a hands-on specialist

Dallas, TX

Property Insurance Claim Specialist

Dallas, TX

McLaughlin, Cole and Bartoletti

Dallas, TX

Property Insurance Claim Specialist

Develop and recommend enhancements to improve operational processes and procedures - Limited latitude
Perform other duties as assigned
Familiarity with Conventional, FHA, VA loans & RESPA guidelines
Communicate with investors amended procedures during periods of declared disasters
Familiarity with Investor, Insurer and Navy Federal guidelines as they relate to mortgage loan origination and mortgage servicing
Maintain accurate and prompt follow-up on billing/payment issues
Familiarity with Fannie Mae, Freddie Mac and/or VA mortgage servicing guidelines

present

Detroit, MI

Electronic Insurance Claim Specialist

Detroit, MI

Schmidt, Bailey and Wintheiser

present

Detroit, MI

Electronic Insurance Claim Specialist

present

Prepare and submit HIPAA compliant claims to 3rd party payors through data exchange programs or as indicated by payor; review claims and account documentation to ensure accurate billing and utilize billing edit reports to correct and revise claims to ensure claim accuracy and prompt billing
Continually interact with various departments to resolve billing edit errors ensuring correct claims submission in an automated billing environment
Maintain job knowledge to effectively carry out the responsibilities of assigned insurance (s) group including CPT, HCPC, ICD-9 coding, occurrence, condition, span and value codes in addition to modifiers
Add and remove charge procedure codes, modifiers, and other codes as directed by clinical department heads
Maintain supporting documentation for all account changes with originating department sign-off
Pursue other insurance information through eligibility verification and check claims status through online access, including WEBMD, NEHEN, REV's, FISS, and individual insurance carriers websites
Investigate and resolve non-routine billing problems with third party payors and federal/state agencies

Education Education

Bachelor’s Degree in Accuracy

Georgia State University

Bachelor’s Degree in Accuracy

Skills Skills

Qualification in a construction discipline, engineering or quantity surveying, with requisite experience, including site based experience
At least 10 years of relevant experience in planning, construction and engineering
An effective communicator, oral and written
At least five years working as a claims scheduler, mainly on the side of a contractor but consultant/client-side exposure is an advantage
Able to carry out document research in a logical, structured manner. The project uses ACONEX
Able to interface with construction team personnel (field) in the validation of evidence (background stories)
Highly conversant with delay impact analysis methodologies and with window analysis processes
Familiar with concepts such as concurrent and parallel delays, excusable/non-excusable, compensable/non-compensable; case law and reference text (e.g. Pickavance, AACE, SCL) knowledge will be an advantage
This is not a management position; this is a position for a hands-on specialist
Single status assignment, grading based on education and experience

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Claim Specialist Resume Examples & Samples

Provide leadership, motivate, mentor and develop staff in all areas of claim adjudication and, in empathetic and professional customer service
Provide thorough analysis, clear and concise recommendations on claims referred by claims analysts and travel provider based on authority limits and contractual provisions
Provide problem and complaint resolution on escalated claims not resolved by the analysts and vendor and co-ordinate responses to claim appeals
Conduct claim audits and Quality Assessments Reviews (QAR’s) and provide feedback and recommendations based on the results
Collaborate with other leaders in TDI to ensure that all claims functions are aligned with the goals and objectives of the organization
Approve large loss claims and provide feedback on case management
Provide input to third party supplier processes and procedures to ensure best practices are followed
Ensure all avenues for financial recoveries, including re-pricing, repatriation, coordination of benefits, subrogation are being explored
Monitor claim SLA’s and ensure timely corrective action is implemented
Compile regular reporting to identify claims trends for travel

Claim Specialist Resume Examples & Samples

Utilize advanced technical knowledge to audit auto claims (strong understanding of comparative negligence application and negotiations) to ensure compliance and quality standards are met. Ensure state and internal compliance and quality is adhered to and requirements are met on a claim file. Responsible for quantifying potential indemnity and expense leakage on auto claims and for coaching representatives on sound claim handling practices
Identify claim process and procedural gaps. Research and implement solutions that are in compliance with state insurance laws. Present recommended changes to senior claims leadership
Assists in developing training and analysis of pilot programs. Develop and lead training sessions to ensure claim team members’ understanding of state compliance requirements, regulatory changes, and vendor changes and reinforce department standards on compliance goals and quality claim management
Act as a subject matter expert on business projects. Assists in managing projects/pilots
3-5 years of relevant claims experience
Ability to obtain state specific property casualty licenses as required
Advanced knowledge of state compliance regulations and interpretation of state statues
Excellent verbal, written and interpersonal communication skills in translating statutes into terminology that representatives understand
High degree of accuracy; strong attention to detail
Experience in personal lines auto claim settlements (with a strong understanding of comparative negligence application and negotiations) demonstrating expert knowledge
Associate in Claims-designation-Am Institute of Chartered Property Casualty Underwriters
Experience in coaching, training and providing feedback to others
Project management experience

Liability Claim Specialist Resume Examples & Samples

Oversee Third Party Administrator (TPA) claims handling to ensure proper reserves, action plans are appropriate and provide settlement authority to ensure equitable resolutions are reached
Conduct audit sessions to optimize claims resolution opportunities
Coordinate with other vendor partners in the process: medical management, telephone reporting, law firms, insurance carrier and Medical providers networks in the jurisdictions
Direct interface with Operations, Human Resources, Safety and Risk Control, Fleet, Legal, and other pertinent Aramark personnel on claims to assist in investigation, return to work opportunities, Interactive process and employee relation matters under ADA and FEHA
Identify trends that impact the financial cost of the claims and bring it to the attention of the responsible parties
Develop and deliver post loss training programs to field personnel for ongoing education and Best Practices compliance
The Sr. Claim Specialist will manage those claims involving severe injuries, extended periods of disability and high value
Interfaces with all levels within the line of business, human resources management, TPA, medical case management vendor, law department and insurance carriers. Must have technical knowledge & experience of the workers’ compensation process. Excellent analytical and verbal / written communication skills. Strong negotiation skills
Perform other duties as required or assigned, which are reasonably related to, or within the scope of the responsibilities enumerated above
The desired candidate will have a fluent understanding of both workers’ compensation and liability claims handling process. This position requires a Bachelor’s Degree in business, risk management or a related field (or equivalent experience) and 5 to 8 years of hands-on lost time claims experience, along with catastrophic claims experience. The candidate must have excellent interpersonal skills and strong verbal and written communication skills. Knowledge of claims database systems is required. An AIC, ARM, or CPCU designation encouraged but not required. Technical expertise in multiple state workers’ compensation laws is desirable. Bilingual desired

Wind Energy Warranty Claim Specialist Resume Examples & Samples

Bachelor’s Degree (or Associate’s Degree with a minimum of 2 years of experience with handling customer claims or High School Diploma / GED with a minimum of 4 years of experience with handling customer claims)
Minimum of 1 year of experience coordinating case volumes and entering information into a database (i.e., Oracle, PeopleSoft, Access)
Previous field experience at a Wind Turbine Park
Previous experience in handling warranty claims
Knowledge and experience with Oracle based tools
Ability and desire to learn new computer applications
Effectively navigate through Microsoft Office Products (i.e., Outlook, Excel, PowerPoint, Word)
Negotiation and interpersonal skills with proven track record of accelerating change
Ability to see the big picture and drill down several layers into the details
Ability to succeed in a matrixed organization, across multiple groups and influence support needed to close out customer issues
Clear examples of cross functional facilitation

Wind Energy Warranty Claim Specialist Resume Examples & Samples

Bachelor's Degree in technical, business or financial discipline from an accredited College or University OR (Associate's Degree from an accredited College or University with a minimum of 2 years of equivalent experience with handling customer claims OR High School Diploma / GED with a minimum of 4 years of experience with handling customer claims)
Minimum of 3 years of experience working with claims and issue resolution, using and applying information in a central database (i.e., Oracle, PeopleSoft, Access)
Previous Field Experience at a Wind Turbine Park experience
Effectively navigate thru Microsoft Office Products (i.e., Outlook, Excel, PowerPoint, Word)

Complex Workers Compensation Technical Claim Specialist Resume Examples & Samples

Investigates claims to determine whether coverage is provided, establish compensability and verify exposure. Resolves claims within authority and makes recommendations regarding case value and resolution strategy to Branch Office Management and HO Examining on cases which exceed authority
Identifies and appropriately handles suspicious claims and claims with the potential to develop adversely
Prepares for and attends mediation sessions and/or settlement conferences and negotiates on behalf of LMG and LMG Insureds
Confers directly with policyholders on coverage and resolution strategy issues
This role offers flexible work options such as part-time telecommuting and/or compressed work week schedules.**
5-7 years of related claims experience with 1-2 years of experience in complex claims
CA SIP and WC CA Certification
CA, UT, AZ licensing recommended

Property Insurance Claim Specialist Resume Examples & Samples

Apply funds to mortgage upon receipt of approved claim proceeds from Insurance company
Communicate with investors amended procedures during periods of declared disasters
Coordinate with default department the application of restricted escrow funds in the event of mortgage default
Ensure adherence within investor guidelines; notify appropriate investor of claim when required
Maintain accurate and prompt follow-up on billing/payment issues
Obtain and process insurance claim checks for immediate release or remittance to restricted escrow account of the mortgage loan per investor guidelines
Order inspection reports at appropriate intervals; review inspection results to authorize and process repair fund release
Prepare accurate documentation and calculation of wire transfers for payment submissions to vendor ledger accounts
Reconcile and balance required remittance to approved vendors for billing & payment - Moderate analysis
Request repair estimates and other required documentation from insurance carrier or homeowner ensuring accurate replacement or repair of documented damage
Resolve escalated discrepancies including guiding and/or negotiating with members and/or Internal/external contacts
Develop and recommend enhancements to improve operational processes and procedures - Limited latitude
Experience in managing multiple priorities independently and/or in a team environment to achieve goals
Experience in member/customer service preferably in a call center, retail banking or financial institution
Familiarity with mortgage insurance operations and procedures
Familiarity with Conventional, FHA, VA loans & RESPA guidelines
Familiarity with Investor, Insurer and Navy Federal guidelines as they relate to mortgage loan origination and mortgage servicing
Effective research, analytical, and problem solving skills
Effective skill following, interpreting and applying relevant data/instructions to guidelines, procedures, practices and regulations
Effective skill interacting with staff, management, vendors and members diplomatically and tactfully
Desired- Experience as a licensed Insurance Agent
Desired - Familiarity with Navy Federal Mortgage Production and/or Servicing Systems
Desired - Familiarity with Navy Federal mortgage products, services, programs, policies and procedures
Desired- Working knowledge of Navy Federal financial and credit transaction documentation processes

Repair Svcs Claim Specialist Resume Examples & Samples

Reviewing and processing >25,000 claims annually
Maintaining review queues, not to exceed a 2 day backlog
Overseeing the Original Equipment Manufacturer claim reject queues to determine whether to negotiate with a vendor for direct payment of the Independent Service Provider or process and pay the Independent Service Provider through the Lowe’s process and funding
Processing all Extended Protection Plan customer buyout and accommodation requests
Reviewing each dispatch and entering the appropriate failure code(s) as interpreted from the description of service preformed and parts used
Developing and monitoring the audit process and queue for the review of parts and labor pricing to ensure Lowe’s is being accurately charged
Training new Claim Coordinators on processing claims
2 year degree OR 2+ years equivalent experience
2-3 years claims experience or equivalent work experience
2-3 years experience negotiating with third parties
4 year degree
Experience with Service Bench software

Senior Claim Specialist Resume Examples & Samples

Investigates and maintains claims. Reviews and evaluates coverage and compensability. Secures and analyzes necessary information (i.e., reports, policies, releases, statements, reports or other documents) in the investigation of claims
Works toward the resolution of claims and attends arbitrations, mediations or trials as necessary
Evaluates reserves and settlements within prescribed limits and submits recommendations to supervisor on cases exceeding authority
Conveys more complex information (coverage, decisions, outcomes, etc.) to all appropriate parties, maintaining a professional demeanor in all situations
Ensures that claims payments are issued in a timely and accurate manner
Ensures 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
May provide guidance and lead the work of less experienced adjusters and other functional areas (mentors, prioritizes, delegates and reviews assignments)
Other duties as needed
Must have a Bachelor's degree and a minimum of 10 years of experience handling workers' compensation claims. Multi-line adjusters experienced in handling workers' compensation claims are are encouraged to apply. Experience handling California workers' compensation claims is preferred
Possesses a high and extensive level of technical knowledge and skills, including product and industry. Recognized as an expert in workers' compensation claims
Able to handle litigated files and closely monitor defense counsel
Must have strong skills in customer service, computers, verbal and written communications, time management, and organizational skills
Able to perform work with limited supervision within prescribed claims authority

Claim Specialist Resume Examples & Samples

Qualification in a construction discipline, engineering or quantity surveying, with requisite experience, including site based experience
At least 10 years of relevant experience in planning, construction and engineering
An effective communicator, oral and written
Fully conversant with P6 8.3 with a minimum of 10 years Primavera related experience
Career experience must come out of the construction industry, including a good civil engineering exposure (horizontal, underground and bridge/viaduct construction; experience in rail and TBM tunneling an advantage); experience in building construction above and below ground a prerequisite
Major contractor experience required and international exposure an advantage (especially Middle East)
At least five years working as a claims scheduler, mainly on the side of a contractor but consultant/client-side exposure is an advantage
Able to carry out document research in a logical, structured manner. The project uses ACONEX
Able to interface with construction team personnel (field) in the validation of evidence (background stories)
Highly conversant with delay impact analysis methodologies and with window analysis processes
Familiar with concepts such as concurrent and parallel delays, excusable/non-excusable, compensable/non-compensable; case law and reference text (e.g. Pickavance, AACE, SCL) knowledge will be an advantage
This is not a management position; this is a position for a hands-on specialist

Electronic Insurance Claim Specialist Resume Examples & Samples

Prepare and submit HIPAA compliant claims to 3rd party payors through data exchange programs or as indicated by payor; review claims and account documentation to ensure accurate billing and utilize billing edit reports to correct and revise claims to ensure claim accuracy and prompt billing
Resolve billing edit errors generated via in-house scrubber reports and claim checks as well as through individual payor editing programs; resubmit claims where appropriate
Continually interact with various departments to resolve billing edit errors ensuring correct claims submission in an automated billing environment
Maintain job knowledge to effectively carry out the responsibilities of assigned insurance (s) group including CPT, HCPC, ICD-9 coding, occurrence, condition, span and value codes in addition to modifiers
Add and remove charge procedure codes, modifiers, and other codes as directed by clinical department heads
Maintain supporting documentation for all account changes with originating department sign-off
Pursue other insurance information through eligibility verification and check claims status through online access, including WEBMD, NEHEN, REV's, FISS, and individual insurance carriers websites
Resolve unbilled accounts through downloaded claim rejection reports, insurance internet websites, and other reports and/or claim listings where appropriate
Investigate and resolve non-routine billing problems with third party payors and federal/state agencies
Perform individual claim entry, adjustments, and cancels, through online access to specific payors websites
Respond to insurer inquiries in a professional, timely, efficient and knowledgeable fashion, ensuring HIPAA guidelines are followed
Maintain knowledge of Microsoft Excel, Word and Outlook to create and maintain logs and reports as needed to support Patient Financial Services activities
Performs related clerical activities such as typing, photocopying, filing, calculating, faxing, mail sorting and distribution, etc. as necessary
Contributes as a team member in support of the hospital and departmental work activities and projects
Assists the department, work unit and/or fellow staff members by covering for absences, training activities, etc
Complies with departmental and organizational policies including but not limited to, dress code, use of supplies, telephones and computers
Adheres to work schedules and maintains a safe and orderly work area at all times, maintaining awareness of and compliance with safety policies and procedures
Attends and participates in educational programs, in-service meetings, workshops, and other activities as related to job knowledge and state guidelines
Clearinghouse experience and ability to analyze automated computer output
Performs other job related duties and assignments as requested
Ability to read, write and communicate in English
2 years education beyond high school at a trade school, technical school or college in healthcare office practices, physician office practices, or financial services AND at least 1 year experience in third party insurance billing in a hospital setting OR minimum 1 years recent experience (within the past 3 years) in a Medical setting
Basic mathematics skills, and ability to apply skills, as demonstrated by successful passage of a timed business math test, using manual and calculator aided computations to solve problems
PC skills, including Microsoft Excel, Word and Outlook, with a minimum of 6 months experience working with Meditech or similar information system on a daily basis
Keyboarding skills at 35 WPM as demonstrated by successful passage of a timed test
Successful passage of a certified hospital billing course or successful passage of CCH in-house hospital billing test
Successful passage of basic medical terminology course OR successful passage of the CCH Medical Terminology exam
Experience using automated billing systems

Casualty Litigation Claim Specialist Resume Examples & Samples

Quality Claim Handling - Determines whether or not proper coverage exists for assigned litigation claims. Investigates thoroughly to obtain relevant facts concerning all aspects of the claim, such as coverage, liability, legal climate, potential exposure, and damages, and makes decisions, where appropriate, on litigation claim resolution. Monitors ongoing case development for appropriateness
Litigation Process - Develops and maintains effective business relationships with counsel. Responsible for the appropriate assignment of counsel on claim files, monitoring counsel’s work product, and partnering with counsel to handle litigation claims in the most efficient manner
Damages - Determines the value of the physical damage of property, automobiles, or injuries through inspections and use of appropriate tools. Obtains all necessary documentation to support claim evaluation. Recognizes claim file exposures and escalates appropriately
Reserving/Reporting - In accordance with Westfield’s reserving philosophy, establishes and reviews proper reserves for each claim based upon thorough investigation, evaluation, and experience. Completes appropriate reports so that the current status of the claim is clearly documented at all times
Customer Service - Ensures customer service excellence. Responsible for the customer and agent experience associated with assigned claims
Litigation Activities - Attends and actively participates in appropriate litigation activities including meetings, depositions, conferences, hearings, alternative dispute resolution sessions and trials
Negotiation/Settlement - Within decision making authority, negotiates timely and appropriate settlements with insureds, claimants, vendors, attorneys, and other insurance companies. Refers claims exceeding authority to appropriate leader or complex claims specialist with recommendations
Communication - Maintains effective and ongoing communications with insureds, claimants, agents, attorneys, other insurance companies, representatives, vendors, and company personnel
Legal Expense Review - Assists in the review of invoices for attorney fees and other expenses submitted by outside counsel to ensure proper expense management
Collaboration - Collaborates with internal/external business partners, and large account customers, seeking and/or providing assistance or input when needed. Collaborates with peers and other departments to make decisions that are in the best interest of the company
Coach/Mentor - Provides technical guidance and assistance to lower level claims professionals and other functional areas
Industry Research/Best Practices - Participates in professional industry groups and stays abreast of industry changes, advancements, and jurisdictional issues to communicate, develop, and incorporate best practices into the claims business. Shares new information, best practices, and processes
Leader Assistance - May travel to assist in complex claims, or may substitute for other leaders
Travel - Travels as often as needed including regular utilization of assigned fleet vehicle in order to cover assigned territory. This may involve traveling on short notice or other daily driving duties as assigned regardless of location
Five or more years of experience handling moderate to high complexity casualty claims with exposure up to $250,000
Two or more years of litigation claims handling experience
Previous commercial lines contract review experience
Construction defect, transportation, and/or general liability experience
Proficient use of various core systems, office and computer equipment and software packages
Conflict resolution experience
Industry recognized designation, such as CPCU, SCLA, AIC, etc
Valid driver’s license and a driving record that conforms to company standards
Bachelor’s Degree or commensurate experience
Ability to work effectively in an office environment for 40+ hours per week (including sitting, standing and working on a computer for extended periods of time)
Ability to communicate effectively in a collaborative work environment utilizing various technologies such as: telephone, computer, web, voice, teleconferencing, e-mail etc
Ability to travel as required
Ability to operate an automobile within the parameters of the driving policy
Ability to drive for extended periods of time, under a variety of conditions, including night driving

PIP Field Claim Specialist Resume Examples & Samples

Conduct kinesthetic interviews of insureds, claimants and witnesses
Conduct scene and vehicle examinations which include reviewing photographs, canvassing for witnesses, reporting duties, utilizing clinic inspections, requesting retrieval and setting of Independent Medical Examinations
Obtain, analyze and summarize police and other database reports, and provider licensing checks
Work in connection with Claims and SIU departments to ensure proper investigation, evaluation and negotiation of claims
Track effectivelyincoming workload as well as outcomes of investigations and recommendations made for further coverage review
Analyze, evaluate and adjust claims within limit of authority in compliance with statutory regulations and fair claim practice, and make decisions on best options as needed
Contact with loss parties within a set timeline
Manipulate large amounts of investigative material within a set timeline
Possess and maintain a Valid U.S. State-issued driver's license
3 years of experience in any combination of the areas: SIU field investigation, Personal Injury Protection handling, or Bodily Injury claims handling in the P&C auto sector
Ability to work in the field, but be open to occasional desk work
Ability to travel up to 75 % of the time
Ability to address difficult situations with tact and diplomacy, but be able to elicit the information required for investigation
Ability to work independently with little supervision; ability to be a self-starter
Investigative background with experience in handling investigations, evaluations, and negotiations of No-Fault and Bodily Injury claims
Possess an understanding of the MI Insurance law, investigation procedures, legal and medical terminology
Ability to build relationships and work closely with a wide variety of team members (POP/BI Teams, SIU, Underwriting and Management
Possess prior external investigations experience in the Insurance industry
Possess prior experience in the investigation of insurance fraud as an SIU investigator
Possess prior experience with advanced interviewing
Successful completion of a kinesthetic interview course