Claims Examiner Resume Samples

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S Kassulke

Schuyler

Kassulke

82018 Leonardo Fork

Dallas

+1 (555) 556 3702

82018 Leonardo Fork

Dallas

Phone

p +1 (555) 556 3702

Experience Experience

Detroit, MI

Claims Examiner

Detroit, MI

Rutherford-Brakus

Detroit, MI

Claims Examiner

Works closely with manager claims examiner, legal counsel, medical director, claims assistants, and other departments
Assists with assignment of daily workflow in the department and client data tracking system
Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles clams within designated authority level
Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level
Reviews incoming Flood Claim documentation, makes coverage decisions based upon established processes, seeking guidance or advice when necessary
Assists Finance with researching provider information to resolve outstanding or stale dated check issues
Openly participate in team meetings, provide ideas and suggestions to ensure client satisfaction, and promote teamwork

Philadelphia, PA

Complex Claims Examiner

Philadelphia, PA

Anderson-Armstrong

Philadelphia, PA

Complex Claims Examiner

Working with Team Manager/Senior Adjuster to ensuring effective vendor and litigation management on Complex claims within a personal allocation
Working with Team Manager/Senior Adjuster to ensure effective vendor and litigation management on Complex claims within a personal allocation
Assisting in continuous improvement across the region through support for the Quality Assurance - - Regional Audit processes
Assist in continuous improvement across the region through support for the Quality Assurance / Regional Audit processes
Providing mentorship to less tenured examiner
Reporting key claims messages to their Team Manager and to internal stakeholders
Ensuring effective vendor and litigation management on Complex Claims within a personal allocation

present

Phoenix, AZ

Senior Claims Examiner

Phoenix, AZ

O'Reilly-Cole

present

Phoenix, AZ

Senior Claims Examiner

present

Accurate and timely review of claim pricing to facilitate manual pricing as necessary, working with various Health Plan provider networks
Reviews incoming Flood Claim documentation, makes Coverage Decisions based upon established processes, seeking guidance or advice when necessary
Effectively communicates with members and providers verbally and in writing regarding claim issues including claim adjudication, subrogation, and overpayments or billing problems
Demonstrate a thorough knowledge of the Plan's claims processing procedures as provided in training materials and proficiency with the core and ancillary system applications
Makes Coverage Decisions based upon SFIP and FEMA language and rules. Prepares and sends Coverage or denial letters when justified o Reviews System work queues, promptly enters or updates data into System in compliance with established processes
Reports directly to the Manager – Risk & Litigation, with ultimate reporting responsibility to the General Counsel, as part of the Legal Team. Works closely with both, in addition to Legal staff, safety, park personnel, insurance carriers and brokers
Work closely with the underwriting department to assist with risk evaluation

Education Education

Bachelor’s Degree in Initiative

California State University, Los Angeles

Bachelor’s Degree in Initiative

Skills Skills

3+ years of experience in a progressively responsible positions in claims
Experience with Claims, Personal Injury, and Workman's Comp Billing/Claims
Strong oral and written communication skills
Ability to work effectively with staff and constituents
Knowledge of applicable claim procedures, statutes, compliance, insurance laws and insurance coverage
Ability to work independently
Strong organizational skills with ability to prioritize effectively and meet deadlines
Proficiency in Word and Excel $
Multi-state experience
Claims experience

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Claims Examiner Resume Examples & Samples

Some claim’s examining experience required whether from examining or answering calls related to claims
Good analytical, organizational and decisions-making skills
Ability to follow policies, procedures and regulations
Sound judgment
PC proficient
Sitting for extended period of time, eye strain from extended use of computer, dealing with difficult/angry customers, meeting deadlines and production requirements

Senior Claims Examiner Resume Examples & Samples

2 years or more claims experience or experience equivalent
Medical terminology or equivalent experience
Ability to follow policies and procedures
Ability to work in a “team oriented” environment
PC proficieint, working knowledge of MS Office products, skilled calculator ability, basic keyboard skills
Mental/visual stress, sitting for extended period of time, eye strain from extended use of computer, dealing with difficult/angry customers, meeting deadlines

Senior Claims Examiner Resume Examples & Samples

Claims evaluation, including minimal referral process
Keying information into appropriate processing system
Researching/Calculations/Investigations
Written correspondence
Other duties as defined by management
2 yrs or more claims experience - we consider talking calls relevant experience
Medical terminology preferred
PC proficient, working knowledge of MS Office products, skilled calculator ability, basic keyboard skills

Claims Examiner Resume Examples & Samples

3+ years of experience in a progressively responsible positions in claims
Bachelor's Degree or the equivalent in work experience
Experience with Claims, Personal Injury, and Workman's Comp Billing/Claims
Knowledge of applicable claim procedures, statutes, compliance, insurance laws and insurance coverage
Strong organizational skills with ability to prioritize effectively and meet deadlines
Proficiency in Word and Excel $

PIP Arbitrations Claims Examiner Resume Examples & Samples

Coverage analysis
Investigation
Litigation management
Reserving
Negotiation/settlement
Other tasks as requested or required
Bachelor's degree or the equivalent in work experience
Three to five years of progressively responsible positions in claims
Ability to work effectively with staff and constituents
High degree of judgment
Multi-state experience

Claims Examiner Resume Examples & Samples

Evaluates and analyzes documentation necessary for claim payments or denials according to the policy/certificate provisions and state regulations with limited authority limits
Evaluates and analyzes documentation thoroughly to determine claim processing according to policy/certificate
Provisions and state regulations with limited authority limits
Long term care examiner is responsible for processing long term care claims within service level standards
Responsible for making phone calls to facilities when necessary in order to gather additional information to process claims accurately
Thoroughly documents correspondence and conversations
Monitors claims for fraud and proceeds accordingly
Infrequently testifies in depositions, hearings and trials; communicates the Company's position regarding the claim
1+ year experience of life/health/disability claim experience or relevant customer service experience
Strong organizational, problem solving and analytical skills
Flexible and adaptable to change
Strong ability to multi-task
Long-term care claims experience

Annuity Claims Examiner Resume Examples & Samples

Evaluates and analyzes documentation thoroughly to determine claim processing according to policy provisions and state regulations with limited authority limits
Analyzes any additional information/documentation received to determine how to proceed with review of claim under supervision and determines methods of obtaining information from alternative sources
Thoroughly documents search for beneficiary and document in detail via phone & written correspondence
Corresponds verbally and in writing with claimants, beneficiaries, funeral homes or other third parties
Works closely with Management, Claims Examiners and Claims Assistants
Assists with department and company projects
Works closely with Legal Counsel, Claims Specialists, Compliance to assist in resolution of claim
Prior customer service related experience
Ability to multi-task and work in a fast-paced environment
Ability to meet department productivity and quality standards regardless of changing environment
Flexible to adjust schedule to meet time-sensitive service levels standards and deadlines
Demonstrated ability in verbal and written communication
Strong teamwork and problem resolution skills
Proficiency in word and Excel
Good organizational, listening and time management skills

Int Cancer / Critical Illness Claims Examiner Resume Examples & Samples

Investigates claims by requesting and interpreting medical records and determining if the medical treatment received is covered by the policy
Reviews application and claims information when a questionable claim is incurred during the two year contestable period
Makes a determination if there is medical history prior to the application date; orders medical records to determine if the questions were answered accurately and initiates policy rescissions when necessary
Ability to process ICU, Heart Specified Diseases, Cancer policies and other riders
Provides customer service to obtain information needed to process claim
Provide timely, written responses to consumer complaints
Respond to questions from customer service representatives
Research and identify current cancer treatments and medications
High school or equivalent
2-3 years previous Claims Experience
Knowledge and understanding of medical terminology, CPT and ICD-9 coding
Good Computer Skills
Knowledge of cancer drugs and the treatment of cancer
Ability to use multiple systems simultaneously

Int Health Claims Examiner Resume Examples & Samples

Provides timely, written correspondence in response to consumer complaints
Conforms with and abides by all regulations, policies, work procedures, instruction, and all safety rules
Minimum 2 years previous health claims processing experience required
Medical terminology, insurance background and knowledge of CPT 4, ICD 9 and HCPCS coding required
Knowledge of PPO networks and discounts required
Strong computer skills with MSOffice and emphasis on Word and Excel preferred
Strong Data Entry skills preferred

Claims Examiner Resume Examples & Samples

Up to 2 years’ experience in claims
Ability to quickly learn product language and provisions
Life Health, Accidental Health Knowledge
Knowledge of medical terminology
Loma Certifications
Experience using MS Word and Excel
Good typing skills

Claims Examiner Sam Resume Examples & Samples

Completion of the employer portion of the Life/AD&D claim form
Collection of all corresponding beneficiary information
Customer Service for beneficiaries
Customer Service for active and retired associates (both phone and walk-ins to the Benefits office)
Assistance with other employer functions tied to the life plans (enrollment, EOI, etc)

Claims Examiner Osg F Resume Examples & Samples

Manage a book of pending claims to ensure timely payments
Render decisions on disability extension requests and traumatic injury claims within authorization limit
Obtain necessary information for claim decisions from various sources including, but not limited to the Veterans Administration, branches of service, beneficiaries, attorneys and police departments
Prioritize work to ensure meeting of performance standards
Strong customer focus skills with high ability to empathize with customers
Ability to learn and retain a large amount of technical information
Excellent PC skills and strong working knowledge of windows-based applications
Ability to work from home when needed. Upon the successful completion of training and meeting all operational metrics, an alternate work schedule is possible

Int Claims Examiner Resume Examples & Samples

Evaluates and analyzes documentation thoroughly to determine claim processing according to policy/certificate provisions and state regulations with moderate authority limits
Analyzes any additional information/documentation received to determine how to proceed with a review of a claim under supervision and determines methods of obtaining information from alternative sources
Manages the investigation of a claim and the outside sources used in the investigation under supervision
Corresponds verbally and in writing with claimants, investigators, medical providers, medical examiners, and law enforcement
Works closely with manager claims examiner, legal counsel, medical director, claims assistants, and other departments
Maintains compliance with regulations and responds to any insurance department complaints
Assists examiner trainees in the system and products
Assists with department and company wide projects
Executes quality review in teams for accuracy and adherence to procedures, sensitive transactions, and regulatory standards; SEC/SOX
Bachelors degree or equivalent work experience required
Minimum of 2 years experience in claims
Know product language and provisions
Learn to cross train with other products
Multi task skills

Lead Health Claims Examiner Resume Examples & Samples

Plans, conducts and assists in the coordination of the workflow assignments and reviews progress
Provides guidance to examiners regarding general and specific claim issues, interpretation of policy contracts and terminology
Process claims that have a high level of complexity or high security level such as internal claims, referrals from agents, etc
Process claim refund checks and overpayments
Maintains records, prepare and compile reports, interpret reports/data related to the claims process
Assists in the ordering of medical records
Assists with the training of new and existing examiners on new process/procedures, systems and products
Corresponds verbally and in writing with claimants, medical providers, and legal counsel, while working closely with the claims manager and other departments
Corresponds with the management team regarding accomplishments, ongoing issues and participate in achieving resolutions to identified issues
Conducts claim audits, tracks information and updates management appropriately
Responds to inquiries and complaints related to claims from the call center, claimants, attorneys, employers, agents, RVP’s and other departments to resolve claim issues
Participates in conference calls with the group, policyholders, agents, etc., to resolve claim issues
Performs claim audits by executing quality reviews for accuracy and adherence to procedures, sensitive transactions, and regulatory standards; SEC/SOX as a result of telephone calls or written requests
Sets daily priorities and is an authoritative resource for other examiners
Uses independent judgment to make decisions in carrying out assignments that have a significant impact related to the business
Obtains and utilizes sensitive information discreetly and objectively
Reviews and authorizes pending claim payments calculated by peers
Attends regular meetings and assists with the hiring of new examiners as directed by management
Knowledgeable of the principles and practices of insurance claims examinations as it relates to timely filings, state specific information and interest calculations
Other duties as assigned based on divisional needs
Minimum of 5+ years of claims related experience with prior insurance experience in a health environment required
Demonstrated analytical and critical thinking skills
Demonstrated ability to exercise independent judgment and make claim decisions effectively
Medical terminology and knowledge of CPT, ICD-9, and HCPCS coding required
Must be able to sit and work at a computer for long periods of time
Advanced knowledge of TEB products
Advanced systems knowledge
Exceptional time management, organizational and problem solving skills
Proficient with Microsoft Office products with emphasis on Word and Excel required

Associate Disability Claims Examiner Resume Examples & Samples

Following through timely on plans
Utilizing judgment and assesses risk when rendering claim decisions
Documenting all claim information including phone calls and correspondence
Utilizing effective communication to obtain information both verbally and in writing, and provides information to the claimant and employer
Ability to apply plan provisions
Managing the needs of the clients
College education is a plus
Prior claim experience preferred
Strong written and verbal communications and time management skills required
Proficiency in PC-based programs such as Word and Excel
Strong mathematical skills desired

Annuity Claims Examiner Resume Examples & Samples

Evaluates and analyzes documentation thoroughly to determine claim processing according to policy provisions and state regulations with increased authority limits
Analyzes any additional information/documentation received to determine how to proceed with review of claim and determine methods of obtaining information from alternative sources
Works closely with legal counsel, Claims Specialists, Compliance, State Agencies
Reviews procedures regularly to ensure they meet compliance with both contractual and regulatory requirements
Investigates missing beneficiaries using all available resources to locate appropriate party
Assists with department and company projects, market conduct exams or other types of audit
Manages the review of the claim promptly until which time all Beneficiaries are paid in full
Assists with training of other examiner’s with systems, products and processes
Reviews and authorizes pending payments calculated by peers
Coordinates activities related with Market Conduct exams, audits, or other regulatory review

Accident DI / Claims Examiner Resume Examples & Samples

Investigate claims by requesting and interpreting medical records to determine coverage
Review application and claim information when a questionable claim is incurred during the two-year contestable period. Make a determination if there is medical history prior to the application date; order medical records to determine if the questions were answered accurately and initiate policy recession when necessary
Ability to process Disability claims, calculate and offset benefits, initiate repetitive payments and waiver of premiums, as applicable
Provide timely written responses to consumer complaints
High School diploma or equivalent required
Minimum of 1 year previous Disability/Accident claims processing experience required
Medical terminology required
Strong computer skills with MSOffice with emphasis on Word, Excel, etc. preferred
Strong 10 key skills preferred

Disability Claims Examiner Resume Examples & Samples

Ability to interpret and apply procedures to resolve issues
Strong analytical research and decision making skills with ability to solution problems, even when the situation is not clearly defined within the procedures
Strong telephone and oral communication skills
Ability to work effectively both independently and as a member of a team
Demonstrated ability manage tasks and time efficiency to meet established production, quality, service and case management objectives
2-3 years disability claims evaluation/processing experience prefered

Workers Compensation Claims Examiner Resume Examples & Samples

Establishes case reserves as required by department guideline and review, analyze and determine a time oriented specific plan of action on assigned cases (Cases assigned may be more complex injuries involving disability management and medical management)
Administer WC benefits as required and in accordance with State of California rules and regulations
Administer benefits, manage disability, medical treatment and litigation issues as they arise
Complex analysis of wages per calculation of indemnity benefits and timely payment of indemnity, medical and allocated costs with emphasis on correctness, efficiency and compassion for the injured worker
Review, analyze and determine any Permanent Partial Disability benefits in accordance with State of California rules and regulations
Litigation management and direction through the WCAB process by utilizing resources provided by the department bringing case to resolution as indicated and required
Addressing in a timely manner medical management and return to work issues within the guidelines set by the Resort and all required State of California notices
5 years experience in management of occupational claims and administration of benefits

Intermediate Health Claims Examiner Resume Examples & Samples

Reviews claim documents submitted by the employee or provider and determines benefit amounts for covered services
Interprets various policies and correctly determines if benefits are to be paid or denied while consistently maintaining quality and quantity standards
Consults with providers and other insurance companies
Acts as a liaison between the customer and the provider to obtain information and resolve claims
Responds to questions from customer service representatives regarding claims issues
Receives and responds to inquiries from producers in a timely manner
Proficiency in CK4, AWD, and ENCORR systems and Claims Mantis preferred

Associate Disability Claims Examiner Resume Examples & Samples

Follows through timely on plans
Utilizes judgment and assesses risk when rendering claim decisions
Documents all claim information including phone calls and correspondence
Utilizes effective communication to obtain information both verbally and in writing, and provides information to the claimant and employer
Manages the needs of our customers
College education and prior claim experience preferred
Experience in effectively meeting/exceeding individual professional expectations and team goals

Claims Examiner Resume Examples & Samples

BS degree or minimum of 1-2 years of equivalent work experience
Experience within a transaction processing environment where quality and quantity standards need to be met is a plus
Strong mathematical/analytical skills, as there are manual calculations
Flexible, proactive and able to work in a fast-paced environment
Flexibility to work overtime when required

Associate Fmla Claims Examiner Resume Examples & Samples

Ability to exercise sound judgement
High level of flexibility to adapt to the needs of the organization
PC skills preferred (i.e. Windows based environment)
College education preferred
Please note, the position is now open to both Scottsdale, AZ and Portland, ME

Associate Disability Claims Examiner Resume Examples & Samples

Heavy written and verbal communication with a diverse population of customers, including claimants with physical and mental impairments, physicians, attorneys, benefit representatives, other healthcare providers, and internal/external customers
Facilitate the technical aspects of claims and appropriately apply contractual provisions and regulatory requirements
Calculate appropriate dates and payment amounts accurately
Develop and maintain effective working relationships with group customers and claimants
Participate in projects/activities related to claim management and process improvement
Prior claims or related experience a positive, but not required
PLEASE NOTE: This position can be located in Scottsdale, AZ; Roseland; NJ Or Portland, ME.*

Claims Examiner Resume Examples & Samples

Conducts investigations and gathers supporting documentation on claims
Calculates benefits payable
Approves (to a specified amount) or denies claims in accordance with established procedures
Bachelors degree preferred or equivalent work experience
Demonstrates strong problem solving and analytical skills
Possesses solid customer service skills and ability to empathize with customers
Ability to work in a fast paced environment and meet metrics
Strong PC skills (Windows based environment)

LTC Claims Examiner Resume Examples & Samples

Incumbents typically have 3-5 years of relevant claims experience
LTC experience is strongly preferred
Strong written and verbal communications are required

Senior Associate Claims Examiner Resume Examples & Samples

Investigates highly complex claims and determines level of resolution if appropriate; advises claimant of status; negotiates settlement and resolution of claim
Schedules work and monitors work performance, including production and quality standards, of lower level claims examiners, as needed. Provides leadership and work guidance to less experienced personnel to ensure accuracy and timeliness of processing. Recommends personnel actions to management and may participate in performance evaluations or counseling employees
Assists in claims financial reporting and reconciliation for client companies
Six or more years of insurance/claims processing experience
Strong interpersonal skills to interact with team members
Strong communication skills to communicate with clients
Strong negotiation skills to interact with claimant
Good human relations skills to provide leadership and work guidance to less experienced personnel

Int Claims Examiner Resume Examples & Samples

Manages the review of a claim and the outside sources used in the review
Corresponds verbally and in writing with claimants, medical providers, medical examiners, and law enforcement
Maintains compliance with regulations and respond to any insurance department complaints

Claims Examiner Resume Examples & Samples

Respond to and initiate a high volume of telephone calls to and from vendors, policy holders and other third party stakeholders associated with the claim and respond to questions regarding flood insurance claims
Enter new flood insurance claims and claim payments, review of all documentation including adjuster reports, engineer reports, underwriting alerts, etc. inputting concise and clear file documentation
Claims will be processed within established policy, company and client guidelines and must be reviewed, based on authority level, by the Claims Supervisor and/or Director prior to payment. Verify and analyze data to ensure that the claims are valid and that the settlements are made according to company practices and procedures
Process claims using various in-house as well as external systems
Ensure all correspondence directed from the Claims Department is professional and complete
Work independently as well as within a team environment
Manage time efficiently and amidst frequently shifting priorities
Participate in a mandatory On-Call phone rotation (two weeks at a time approximately twice a year) to open new flood claims from home during non-business hours
Two or more years of office and/or administrative background required
Two or more years of customer service experience including heavy telephone contact required
Two or more years of prior work involving insurance claims processing required
Excellent reading comprehension with great attention to detail
Ability to apply logic and reasoning to evaluate and resolve claims
Demonstrated verbal and written communication skills including effective de-escalation and mediation techniques
Demonstrated experience in maintaining a high degree of confidentiality and ethical behavior
Required to meet or exceed established expectations for the position
Ability to work independently with a high degree of initiative and limited supervision
Reliability and dedication to the position is imperative
Able to shift between priorities as needed throughout the workday both by direction and instinctively based on pre-established priorities
Knowledge of basic equipment functions, such as how to create and maintain files, printing, copying, faxing, phone messaging and voicemail
Ability to work with frequent and multiple policy, procedure, and regulatory changes

Claims Examiner / Claims Specialist Resume Examples & Samples

Sets adequate reserves to ensure proper reporting
Compares data on claim form with insurance plan to ascertain completeness and validity of the claim
Examines claim form and other records to determine insurance coverage
Proactively works to resolve claim as expeditiously as possible
Reviews and analyze detailed medical records
Calculates reimbursement of benefits according to the schedule of coverage. Runs various claim reports as directed by the account
Cultivates relationships
Incrementally increase productivity without jeopardizing quality
Functions as a resource for examiners and assist with training new examiners and customer service representative
Handles difficult phone calls and composes special correspondence
Works on special projects and other tasks and duties as assigned
3 – 5 years claims adjudication experience
Writes clearly, concisely and effectively
Communicates verbally effectively and with impact
Detail oriented. Ability to multi-task Manages time effectively

Senior Claims Examiner Resume Examples & Samples

Investigates, verifies and analyzes complex coverage issues; resolve in accordance with insurer protocol
Investigate, analyze and evaluate damages and liability factors, including risk transfer opportunities and third party involvement
Handles more complex and higher valued claims
Demonstrate an awareness of jurisdictional nuances impacting claim evaluation and keeps abreast of legislation and court decisions in multiple jurisdictions
Establish and monitor loss and expense reserves within authority level
Complete reports timely and accurately in compliance with company guidelines
Initiate management review of cases with potential to exceed authority level
Develop and implement an appropriate resolution plan
Conduct direct negotiations or, if warranted, mediated settlement discussions
Review and approve payments within authority level
Attend mediations, settlement conferences, or trials as required
Exhibit exceptional organizational skills and computer literacy
In the absence or the Claim Manager this individual will be able to act on their behalf
Exhibits excellent verbal and written communication skills and upholds the organizations values and is a positive spokesperson for the Company

Senior Assistant Claims Examiner Resume Examples & Samples

Enters insurance claims received electronically or in written form
Investigates simple to moderately complex claims and determines level or resolution if appropriate; advises claimant of status; assists in negotiating settlement and resolution of claim
Two or more years of auditing, accounting, contracts or information technology experience
Experience working with insurance and/or medical terminology
Experience working with appropriate claims processing procedures and documentation
Good interpersonal skills to interact with team members
Good communication skills to communicate with clients
Good data entry skills
Negotiation skills to interact with claimant
Ability to keep sensitive and confidential material private

Claims Examiner Resume Examples & Samples

5 years of medical claims examination experience
In-depth knowledge of claims processing protocols and payment schemes
Experience handling Personal Health Information (PHI) in a professional manner
Experience manipulating and entering accurate data in a production driven environment
Relevant professional designation or certification (AIC, ICD 9/10, etc.)
Demonstrated capacity to balance competing priorities and continue to execute projects with excellence
Proven track record in leading peers in organic and formal settings
Strong quantitative analysis skills
Strong Excel skills

Claims Examiner Resume Examples & Samples

Provide expertise or general claims support by reviewing, researching, investigating, negotiating, processing and adjusting claims
Authorize appropriate payment or refer claims to investigators for further review
Analyze and identify trends and provides reports as necessary
Consistently meet established productivity, schedule adherence, and quality standards
Provide excellent customer service
Excellent Data Entry skills needed
Revenue and HCPCS coding skills helpful
Experience in contract interpretation
Medical Insurance Industry processing required
2 years experience as a Medical Claims Examiner
Working knowledge of Medical Terminology, ICD9, CPT4, UB92/1500 forms
Excellent Data Entry skills
Medical Insurance Industry processing
1 year experience of Professional claims processing
Prior Medicare, HMO experience
Revenue and HCPCS coding skills

Claims Examiner Resume Examples & Samples

Perform three-point contact with Injured Worker, Facility Manager and Physician. Investigate (field or otherwise) all injuries, determine compensability of the claim, evaluate liability/exposure, identify and pursue subrogation and/or salvage and prepare proper reports as required. Evaluate and maintain timely claim reserves
Manage medical treatment, medical utilization, authorize, control and process bills within guidelines by using cost containment program; audit provider bills. Work with injured workers, facility managers and physicians to aid in the return to full or modified work duties
Manage the litigation process. Develop settlement and negotiate strategies with attorneys and injured workers, execute settlement documents and issue settlement benefits as approved by the WCAB or ADR mediators. Determine need for and direct defense counsel, independent examiners, or other experts and monitor and control their costs
Insure all WCAB and ADR filings are timely, handle WCAB/ADR administrative inquiries, and attend WCAB/ADR hearings
Communicate and interact with facility managers, injured workers, attorneys, physicians, vendors, Disability Evaluation Bureau, WCAB, etc., as needed. Interact with Division and Corporate Departments to obtain information necessary to resolve claims, discuss safety awareness and understand contractual issues presented to the company. Keep facility managers and appropriate risk management department personnel advised of file status
Prepare excess reporting as required. Insure accurate coding of data within the claims system. Identify and report all fraud. May represent the company at Boards Hearings or conferences
Minimum of six (6) to eight (8) years plus the education listed above
Minimum of five (5) years claims examiner experience
Knowledge of the States Workers' Compensation system principles, statutes and judicial protocol. (Benefit calculation, compensability decision time line factors, and subrosa)
Knowledge of hearing and trial process and procedures
Knowledge of OSHA and state reporting requirements
Permanent disability systems and calculations Claims system coding and use
Strong interpersonal, negotiation and customer service skills
Capable of dealing with demanding customers
Must be able to effectively work in a team environment
Computer literate and knowledge of computer claim applications and Microsoft Office Suite preferred

Healthcare Claims Examiner Resume Examples & Samples

Experience in processing claims for inpatient, outpatient facility and professional services
Be able to integrate knowledge as a skilled specialist
Possess deep domain knowledge in Healthcare and Insurance domain

Junior Claims Examiner Resume Examples & Samples

Investigate pre-suit claims and disposition of potentially compensable events
Establish and review reserve information quarterly
Update and maintain claims database; input into national claims-related databases
Compile requested information for management reporting, update and maintain claims calendar, and maintain claims files
Attend meetings with physicians and managers
Meet with claimants to negotiate settlements
Minimum two (2) years of experience with a commercial professional liability insurer preferred
Investigate pre-suit claims related to low exposure medical malpractice, professional liability and general liability matters (dental injury, slip & fall, vehicular damages, etc.)
Ability to communicate, write and negotiate with doctors and attorneys
Interaction with outside counsel, various levels of management, including providers. medical group contacts, public affairs, attorneys, risk managers regarding low exposure medical and legal issues
Ensure compliance with internal PPL policies for management, handling & reporting of small claims

Claims Examiner Resume Examples & Samples

Investigate pre-suit claims and disposition thereof, if appropriate (including selection and retention of medical experts and negotiation with claimants
Analyze and prepare responses to discovery requests (including interrogatories and responses to requests for production of documents)
Update and maintain claims databases; input into national claims-related databases
Attend significant depositions, hearings, settlement conferences and trials
Ability to effectively and professionally communicate with Leadership, healthcare providers and lawyers both orally and in writing
Minimum seven (7) years of experience with a commercial physician professional liability insurer or equivalent legal experience

Claims Examiner Resume Examples & Samples

Collects data and processes death claims
Communicates claim decisions to our beneficiaries by phone and through mail
Bachelors degree or equivalent work experience

Claims Examiner Resume Examples & Samples

Maintain thorough documentation and confidentiality
Performs other assigned duties / special projects on an as-needed basis
2+ years experience in claims payment and adjudication for an IPA, or other health care company
Knowledge of medical terminology, CPT coding and physician reimbursement methodologies such as RBRVS
Strong computer experience (minimum 1 year experience with EZ-Cap preferred)
High school diploma (or equivalent)

Claims Examiner Specialist Resume Examples & Samples

General office equipment experience (i.e. photocopier, fax, calculator, ability to operate a PC and previous exposure to the Microsoft Windows environment)
Must have an excellent understanding of health and managed care concepts and their application in the adjudication of claims
Strong working knowledge of ICD.9.CM, CPT, HCPCS, RBRVS coding schemes and medical terminology
1-2 years of claims processing experience in a PPO, self-funded, and/or HMO setting preferred

Claims Examiner Supervisor Resume Examples & Samples

Hourly Monitors inventory reports and assigns work queues based on staffing and/or volume reassess, identifies and distributes unprocessed work to staff on a first-in first-out basis or other established priorities
Contributes to daily production standards and output as set forth by the Claims Manager
Works collectively with all levels of management and staff to ensure compliance with inventory production and timeliness standards
Reviews daily operational reports as many times as needed throughout the day to assure compliance
Maintains controls to insure that all claims are processed within regulatory requirements
Identifies training for staff failing to meet established minimum production and quality objectives. Responsible for staff orientation and training
Coordinates system access rights for new staff and distributes department training materials, approved policies and procedures, and such other approved reference materials as may be required for performance of the examiner’s job functions
Assists manager with unit meetings to review new policies and procedures and training issues
Assist management completing Compliance Corrective Action Plans for the Claims department
Maintains and keeps in total confidence, all files, documents and records that pertain to the operation of the business
All other job related duties as it relates to the job function or as delegated by the management team

Disability Claims Examiner Resume Examples & Samples

Facilitate the technical aspects of the claim and appropriately apply the legal and contractual provisions
Calculate appropriate dates and payments amounts accurately
Proven skills in positive and effective interaction with customers
PC skills required (i.e., Windows based environment)
College degree preferred, and prior claim experience required

Senior Disability Claims Examiner Resume Examples & Samples

Heavy written and verbal communication with a diverse population of customers, including claimants, physicians, attorneys, benefit representatives, other healthcare providers, and internal/external customers
Understand and correctly utilize the appropriate systems
Ability to manage multiple and changing priorities
Strong written and communication skills demonstrated in previous work experience
Specific experience with collaborative negotiations
Demonstrated analytical and math skills
Experience managing complex disability claims and coaching/developing less experienced team members

Senior Claims Examiner Resume Examples & Samples

Examine and adjudicate claims and ensures claims are paid and entered into system within AB 1455 and Medicare Guidelines
Audit all paper and electronic claims for accuracy
Verify member eligibility with Eligibility Department as necessary
Handle physician, HMO and patient inquiries on claims status, as necessary
Learn and apply the mandated health plan and IPA procedures for denied claims
Process denial letters using HMO required format on a weekly basis
Foster positive interaction and relationships with all internal departments as well as cultivating positive working relationships with external contacts
Prepares claims for Scanning and Inloads
Inloads claims
Handles issues with Medical Director to ensure proper payment of claims
Runs Crystal reports for Management upon request
Assist with timely review of claims payment and all Health Plan audits
5+ years experience in claims payment and adjudication for an IPA, or other health care company
Must maintain confidentiality
Experience with computer programs (Windows, Word, Excel, Mail Merge, Fax Blast, PowerPoint)
Excellent communication and assessment skills
Willingness to learn new tasks

Claims Specialist, Claims Examiner Resume Examples & Samples

Enter new flood insurance claims and claim payments, review of all documentation including adjuster reports, engineer reports, underwriting alerts, etc. inputting concise yet sufficient file documentation
Claims will be processed within established company and client guidelines and must be reviewed, based on authority level, by the Claims Supervisor and/or Director prior to payment. Verify and analyze data to ensure that the claims are valid and that the settlements are made according to company practices and procedures
Apply National Flood Insurance Program rules and regulations with each flood insurance claim processed
Respond to a high volume of telephone calls both regarding flood insurance claims and field complex questions from customers, clients, and insurance agents
Complete company training program. Program includes inter-departmental training within the Operations department as well as classroom training
Maintain an established level of productivity using time management techniques
Able to shift between priorities as needed throughout the workday
On Call phone rotation, two weeks at a time, approximately twice a year to open new flood claims from home
1+ Years of Office and/or Administrative background
Strong customer service experience including heavy telephone contact
Prior working knowledge of insurance claims processing preferred
Excellent communication skills including both verbal and written, with specific attention to detail
Ability to maintain and display a positive attitude at all times; supporting business needs and changes; supporting continuous improvement; and supporting the National Flood Insurance Program
Ability to work independently with a high degree of initiative
Reliability and dedication to the position is imperative. Position will frequently require overtime hours
Proficiency at keying alpha and numeric information with accuracy and speed
Strong proficiency in Excel and Word
Uses vision to view screens, create and review documents; requires close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus
Capable of using a keyboard effectively
Frequently required to sit for long periods of time, stand, walk and may occasionally lift and move 25 pounds
Occasional travel to meetings or outside training may be required
Due to the nature of the business, overtime may be required

Claims Examiner Resume Examples & Samples

Demonstrates regular, reliable and predictable attendance
Determines the level of reimbursements based on established criteria, provider contract, special global contract for professional and institutional claims for insured services, eligibility guarantee, special pool, benefit plan and employer group provisions, for multiple products
Processes all routine claims eligible or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner. Researches any missing or required information
Documents provider claims/billing forms to support payments/decisions. Matches authorizations to claims, maintains current desk procedural and reference materials
Responds by telephone or in writing to providers, members, or other company departments to process and resolve the claim issue
Maintains/updates knowledge of all claims products, contracts and standard reference materials (COB, CFA, AMA, WC, TPL, DOC codes)
Researches/adjusts requests for overpayment, underpayment, and contract issues to ensure compliance with departmental and company policies and procedures
Develops/maintains effective business relationships with internal and external clients
Ensures compliance with government regulations and requirements NCQA, DOC, HCFA
Processes claims through the PMG automation system, ABS, MS Excel and 20/20 spreadsheet
May assist in system testing, and reporting of specific enhancements for various product lines
Ability to operate PC-based software programs or automated database management systems preferred
Excellent written and oral communication skills, as well as analytical skills required
Knowledge of standard claims forms and coding used for physicians billings; ability to read/interpret contracts; knowledge of standard reference publications (RBRVS, CPT, ICD-9; complete product and benefit coordination knowledge
Proficiency in interpretation and application of service/legal contracts required
Ability to efficiently and effectively prioritize a large volume of production work to meet deadlines

Claims Examiner Resume Examples & Samples

Minimum of one year Anthem medical claims processing experience (internal applicants shall have preference over outside applicants) or medical claims processing/or other health insurance or equivalent education
Familiarity with basic arithmetic computations and data entry principles
Thorough knowledge of medical terminology and codes

Workers Compensation Claims Examiner Resume Examples & Samples

Evaluates new and on-going claims to determine liability, giving consideration to contract provisions, disability management duration contract guidelines, medical evidence and vocational evidence
Investigates questionable claims. Determines need for additional medical information
Performs periodic follow-ups to verify continued existence of a disabling condition
Responds to telephone and written inquiries from claimants, attorneys, physicians and policyholders
Identifies and forwards claims to specialized internal and external resources in areas such as rehabilitation, investigations, medical exams, settlements and Social Security
Keeps track of time frames required of mandated correspondence
This level is responsible for independently reviewing simple to moderately complex claims for adjudication purposes. Refers more complex claims to higher levels
Ability to multi-task and understand multiple products and multiple levels of benefits within each product
Excellent analytical and problem solving skills required

Claims Examiner Resume Examples & Samples

Communicate openly with all claim stakeholders (Cast Member, Medical Provider, Return to Work, Nurse Case Manager, Team Manager, Area/Line of Business, attorneys, vendors, and other partners as required)
5 years’ experience in management of occupational claims and administration of benefits
Solid understanding of the State of California rules and regulations, the recent changes in the laws driven by recent reform including Utilization Review for medical care, Independent Medical Review and Independent Bill Review
Excellent communication skills (listening, verbal and written)
Solid understanding of what it takes to be a proactive, inclusive team member
Self-Insurance Plans Administrator Certificate, 5 years minimum claims administration experience, Bilingual
High School Diploma or equivalent

Disability Claims Examiner Resume Examples & Samples

Manages assigned caseload of more complex Waiver of Premium disability cases
Evaluates claimant eligibility
Utilizes specialty consulting resources effectively including medical, legal, vocational and/or rehabilitative staffs to achieve optimum outcomes for claims direction
Interacts with internal and external customers including, but not limited to, claimants, employers, physicians, attorneys and underwriters to gather the information to make the decision on the claim
Decides payment period, follows up and monitors payment accuracy and timeliness; follows plan to closure
Incumbents typically have 3-5 years of relevant experience
Typically reports to Supervisor of the Wavier Capability
Proven skills in positive and effective interaction with challenging customers
High level of flexibility to adapt to the needs of the organizations

Associate Disability Claims Examiner Resume Examples & Samples

Manages assigned caseload of Disability Waiver of Premium Claims
Inputs claimant medical and demographic data; evaluates claimant eligibility and develops plan to address obstacles
Utilizes specialty consulting resources effectively including medical, legal, vocational and/or rehabilitative staff to achieve optimum outcomes for claims direction
Interacts with internal and external customers including, but not limited to, claimants, employers, physicians, attorneys and underwriters to gather the information needed to make the decision on the claim
Analyzes, approves or denies Disability Waiver of Premium claims for contestable and non-contestable cases
Decides payment period, follows up and monitors payment accuracy and timeliness
Provides technical direction to other claims personnel as needed

Senior Claims Examiner, Integrated Absence Resume Examples & Samples

Delivers routine and non-routine work independently, in accordance with established procedures and guidelines, in a timely manner and meets deadlines
Makes routine and non-routine decisions, applying limited but increasingly more discretion within role except for matters of significance which affect the business as a whole or a significant part of it, in accordance with established procedures and guidelines
Applies expanded knowledge obtained from the role in increasingly more complex situations and continues to acquire more knowledge to apply in role
Works overtime as needed

Senior LTD Claims Examiner Resume Examples & Samples

Responsible for the investigation, evaluation, interpretation and determination of the most complex LTD disability claims with sound and impartial judgment
Perform independently using appropriate duration guidelines when necessary
Facilitate effective transition of a STD claim to LTD
Interpret contract provisions, vocational and medical information independently
Solves problems independently
Effectively explain the most complex claim situations
Conducts high-level negotiations in identifying potential settlements
Interpret contract provisions and medical records independently
Interact with claimants, policyholders, attorneys, physicians and brokers directly either orally or written
Responsible for internal and external customer satisfaction in the resolution of claim-specific issues
May act as a resource to our Legal department as it relates to compliance, legislative, legal and regulatory issues
Demonstrates positive leadership ability and a high level of self-leadership
Actively leads by example and by coaching, giving feedback, mentoring and improving quality of LTD claim practices
Works on complex projects at the discretion of the Supervisor, Disability Claims
Works closely with re-insurer on high benefit claims
Performs quality audits and assessments on newly hired Associate Benefit Specialists
Distributes the work of absent employees under the supervision of the supervisor
College degree or equivalent work experience is required
Two to three years of LTD claims experience is preferred, or demonstrated proficiency in current job
Able to read and correctly interpret a Disability contract is mandatory
Strong knowledge of IBM software programs including but not limited to

Auditor of Claims Examiner Resume Examples & Samples

Facilitates and measures whether procedures, processes and controls are consistently achieved based on established service standards
Provides feedback and direction to staff to ensure established processes and procedures are followed
Identifies trends, issues and training needs; and communicates results to leadership

Claims Examiner Senior Resume Examples & Samples

Responsible for quality and continuous improvement within the job scope
Responsible for all actions/responsibilities as described in company controlled documentation for this position
Contributes to and supports the corporation’s quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation’s quality improvement efforts
Processes medical claims (CPT, ICD-10, and Revenue Coding) at productivity standard of 10-15 claims per hour according to contractual agreements
Follows up on claims within one-three day of pending
Reviews batches of claims in order to ensure accuracy of payment
Responds to Member Service inquiries and makes needed adjustments
Attends weekly team meetings
Provides support to Network Services and Administrators
Ensures turnaround time goals are achieved on claims
Edits claims after audit process is complete
Assists other claims examiners as needed
Minimum eight years of claims processing experience, preferably in managed care environment with manual benefit determinations and calculations
Knowledgeable in DRG, modifiers, per diem and other forms of reimbursement required
Knowledge, Skills and Abilities
Comprehensive knowledge of all coding structures (CPT, ICD-10, HCSPCS, etc)

Assistant Claims Examiner Resume Examples & Samples

Answers incoming customer calls regarding claim processing. Documents claim and associated history
Evaluates available information to validate straightforward basic claims. Verifies policyholder information, policy effective dates, premium status and verification of claim eligibility
Sends claim form to claimant for updating, correction or completion
Advises claimant of status and resolution of claim. Escalates claimant concerns as appropriate
High school diploma or G.E.D
Zero or more years of claims experience
Interpersonal skills to interact with team members
Communication skills to communicate with customers
Data entry skills

Senior Claims Examiner Resume Examples & Samples

Establish and quarterly review of reserve information
Retain and direct defense counsel in the event that early disposition is no appropriate or possible
Monitor status of cases and outside counsel compliance with litigation guidelines
Compile requested information for management reporting, update and maintain claims calendar; maintain claim files
Effective Work with Risk Management and HCOM Departmsn in imporving quality of care and resolving adverse outcomes

Claims Examiner Resume Examples & Samples

1) We do the right thing
2) People count
3) We hold ourselves to very high standards

Claims Examiner Resume Examples & Samples

Review pricing methodology for multiple plans
Ensures compliance with all applicable Federal, State and/or County laws and regulations related to our documented guidelines and processes
Maintains compliance with all company policies and procedures
Processes claims by entering patient, payment and provider information timely and accurately from a UB or CMS claim form
Identify and correct any and all duplicate or corrected claims received
Adjudicate claims with a high level of productivity (average 150 claims per day) and minimum average accuracy levels (Procedural accuracy of 97.0% and Financial accuracy of 97.0%) in accordance with all departmental standards
Claims payment
Analyzing medical insurance claims for possible claim errors
Complete other tasks, as assigned
Answer and respond to internal and external emails in a professional and courteous manner
Familiar with CPT, HCPCS, ICD-9 and ICD – 10 code sets
Medicare and Medicaid experience
Medical claims experience
Knowledge of medical billing practices
Computer proficiency (MS Office Suite and Outlook)
Understanding and ensures compliance of HIPAA laws and regulations
Able to differentiate between primary and secondary insurance payers
Must be well organized and detail-oriented
Must be able to work extended hours when necessary
Type minimum 60 wpm
Strong 10 key skills by touch
Able to adapt and apply additional training initiatives
Able to differentiate between international and domestic coding guidelines
Ability to read or have worked with Explanation of Benefits and payments
Claims Adjustments experience

Dental Claims Examiner Resume Examples & Samples

Ensures the accuracy and completeness of submitted dental claims
Escalates claims issues/concerns to more senior team members and/or management
Processes assigned highly routine dental claims for payment or denial in accordance with established procedures and guidelines, in a timely manner and meeting departmental quality/production standards
Provides customer service to internal and/or external stakeholders, recognizes what needs to be done to meet customer needs and demonstrates flexibility and responsiveness to meet customer needs
Reviews submitted dental claim information for payment
Delivers highly routine work and provides general information, in accordance with established procedures and guidelines, in a timely manner and meets deadlines appropriately
Performs basic task/transactions related to common programs and services by acquiring core knowledge required for the role
High School or GED (Minimum Required)
0-1 year of claims experience that directly aligns with the specific responsibilities for this position OR for candidates with an Associate’s Degree or above, 0-1 year of claims experience that directly aligns with the specific responsibilities for this position strongly preferred
Educational experience and/or proficiency is the use of standard office equipment (telephone, P.C. copy, and fax machines)

Claims Examiner Resume Examples & Samples

Processes claim adjustments and reprocessing of system processing errors
Prevents duplicate claim payments
Assists Finance with researching provider information to resolve outstanding or stale dated check issues
Reviews inbound customer service issues, processes related adjustments, handles urgent Customer Service request and communicates outcome in writing and/or verbally to internal staff and external clients as necessary
Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases
Reviews and processes pended claims using pended claim reports
Identifies opportunities for auto-adjudication through review of pended claim reports
Assists Claims Lead with pre-check run audits and perform 100% client audits
Assists in training new Claim Examiners
Processes forwarded claims from the Health Plan
Process pending eligibility claims
Reset accumulators for adjustment claims
High school education or GED
3+ years of previous medical or vision claims processing experience
Knowledge of CPT, HCPCS and ICD-9 coding
Able to perform adjudication of claims using pricing, benefits and eligibility in order to identify incorrect coding, processing errors and overpayments

Claims Examiner Resume Examples & Samples

College degree OR 3 years working experience
6 months experience as a Claims Examiner or materially relevant knowledge, skills and abilities from other professions (e.g., loss prevention, customer service, investigative experience, legal experience, property estimating experience)
Relevant professional licenses and/or certifications, including a North Carolina insurance adjuster license
Flexibility to work beyond normal business hours when necessary
Previous big box retail experience

Claims Examiner Resume Examples & Samples

Evaluate claims to determine potential exposure; make recommendations concerning the value of the claim; oversee litigation and assist in the negotiation of settlements
Proactively oversee the Worker’s Compensation claims management activities in assigned territories with a special focus on cost containment strategies
Manage and target aggressive resolution of case inventory, and resolve problems of varying scope and complexity in accordance with state statutes
Evaluate claims for settlement and appropriateness of established reserves
Attend claim reviews; complete follow up action to ensure expedited resolution
Provide daily support / guidance to teammates, claims adjusters, insurers, and defense counsel by answering claims-related questions or concerns in the administration and management of claims, return-to-work issues, and other claim matters
Analyze claims data to identify needed loss control interventions and assist with the development of appropriate loss prevention programs as requested
Provide training and education to facilities on claim processes and procedures
Coordinate handling of claim subpoenas in an expeditious manner
Generate reporting and analysis on assigned case inventory
Escalate exceptions, outliers, or circumstances that are out-of-norm, as they occur, and seek guidance in case resolution
Participate in meetings, presentations, and special projects, as necessary
Other duties and responsibilities as assigned including but not limited to
(Education, licenses, certifications, and experience required to fulfill the essential duties, include computer skills as required)
Bachelor’s degree in related area required
Workers’ Compensation certification preferred, e.g. WCCP, WCCA, etc
Minimum of three years’ experience handling Workers’ Compensation claims is required
Intermediate computer skills and proficiency in MS Excel, Outlook, Word, PowerPoint, and web based claim data systems is required
Commitment to Company’s values of Service Excellence, Integrity, Team, Continuous Improvement, Accountability, Fulfillment and Fun with ability to demonstrate those positively and proactively to patients, teammates, management, physicians, and/or vendors in every day performance and interactions
Demonstrated sound judgment and initiative in working within departmental and corporate guidelines, including the ability to maintain confidentiality of information
Strong written, verbal, and interpersonal communications skills including ability to listen attentively and to communicate information clearly and effectively throughout all levels of the organization with audiences of varying degrees of familiarity with material

Claims Examiner Medical Malpractice Resume Examples & Samples

Investigate, negotiate and resolve complex medical malpractice, specified medical, allied health, and senior care matters
Maintain and adhere to Markel’s guidelines and procedures
Ensure proper adherence to internal large loss and claims review reporting requirements
Promptly communicate with Claims Manager on adverse case developments and provide information on pertinent issues affecting the Global Medical and Healthcare Practice Group business
Contribute to and assist in the implementation of a wide range of initiatives, strategies and action plans brought forth by the Claims Manager
Communicate with underwriting as needed to manage claims and to alert of any significant developments
Manage any TPA relationships to include reporting responsibilities
Participate in agent and insured related functions and meetings as required
Actively participate in the ongoing training and development activities of the Global Medical and Healthcare Practice Group as indicated by Claims Manager

Claims Examiner, Medical Resume Examples & Samples

Complete and document claim contacts and investigations
Determine coverage and compensability
Assign reserves
Collaborate with Claims Associates for support
Provide high level customer service to callers
Conclude claims with appropriate resolution

Claims Examiner Resume Examples & Samples

Provide professional assistance to adjusters, law enforcement, attorneys, etc. that are involved in incidents where there exists potential liability and claims against the Company
Manage routine and emergency situations for vehicular accidents, drug/alcohol allegations and safety issues with drivers, workers compensation claims, or cargo claims for your assigned area
Evaluate legal liability, exposure to risk, and dollar value of damages for management review
Maintain a suspense system to ensure regular review of case files. Monitor case files daily to determine if reserves are set accurately and adjust within your authority
Assess liability to apportion damages based on percentage of negligence for negotiating settlements with claimants, attorneys and insurance companies
Conduct initial and follow up contact and/or correspondence with claimants, insurance companies, attorneys, etc. regarding claim submission
Negotiate with plaintiff attorneys, insurance companies, etc. to settle vehicle and/or personal injury claims within your individual authority limits
Maintain current knowledge of federal, state, and local laws and regulations applicable to your area of responsibility

Claims Examiner Resume Examples & Samples

At least 3 years’ experience in P&C insurance
Attain ANFI certification within one (1) year of hire
Apply for and obtain FCN within two (2) years of hire

Claims Examiner Resume Examples & Samples

Reviews initial loss reports. Evaluates exposure and sets reserves. Directs and oversees the independent adjusters in the investigation, management and handling of accidents and claims. Reviews adjuster reports to determine settlement or denial of claim. Participates and coaches independent adjusters on settlement negotiations. Authorizes and requests issuance of settlement checks. Reports and presents recommendations of significant exposure to Senior Manager. Audits the independent adjustors for performance on claims handling including the areas of evaluation of exposure, recommendations for handling and resolution (settlement or denial) of claims. Manages the performance of the independent adjustors to ensure data integrity, proper payment of claims and compliance with contractual requirements. Monitors independent adjustors for closing effectiveness and claims costs
Five (5) years experience required in claims or related area
Software skills, including use of Microsoft Office software and web-based applications. Verbal and written communication skills necessary to explain complex and/or confidential information. Time management, organizational and multi-tasking skills necessary to work in a fast-paced environment, handling various tasks and changing priorities, while maintaining a high attention to detail and accuracy to achieve daily assignments and goals. Ability to analyze, review, and make recommendations. Knowledge of concepts, practices, policies and procedures related to tort law/legal system/contracts and general knowledge of liability insurance coverage
5 years of experience handling commercial auto, bodily injury, and general liability claims
Experience with multi-jurisdictional claims handling
Industry designation (AIC, SCLA, or CPCU)
Excellent communications, evaluation, and negotiation skills
Leadership ability and time management skills to organize effectively

Claims Examiner, Osgli Resume Examples & Samples

Manage a book of pending claims through effective time management to ensure timely payments
Obtain necessary information for claim decisions from various sources including, but not limited to, the Veterans Administration, branches of service, beneficiaries, attorneys and police departments
Correspond with claimants, law department, underwriting, Casualty
Assistance Officers, attorneys, the Veterans Administration and other interested parties through the life of a claim
Customer Service experience preferred
Strong problem solving, strategic thinking and analytical skills
Ability to prepare replies to claim inquiries
Ability to prioritize work and excel in a fast-paced, metric driven environment
Attention to details a must
Prior claims experience a plus
Ability to work from home when needed
Upon the successful completion of training and a period of time of meeting all operational metrics, an alternate work schedule is possible
Bachelor's Degree or equivalent military experience a plus

Complex Short Term Disability Claims Examiner Resume Examples & Samples

Conducts initial liability review and completes detailed initial phone interview with claimant
Reviews claim payments within established limits and/or reviews recommendations made by medical sources to determine proper disposition of claims
Sets claim action plan to ensure that determinations are adjudicated in a timely, accurate, and efficient manner
Interprets contracts and ensures consistent, fair claims practices and adherence to appropriate laws, regulations, and procedures
Obtains backup documentation, as necessary, to substantiate claim or to provide service by communicating via telephone with agents, employers (policyholders), claimants, hospitals, physicians, attorneys, and other resources
Assesses occupational job duties and rehabilitation opportunities by working with vocational staff
May handle other related duties such as providing technical assistance to other Claims staff or assisting in special projects or assignments as a result of business needs
Associate’s or Bachelor degree in psychology or related field would be an advantage
Claims experience required
1-2 years of customer service / financial services experience
End user computing skills including proven proficiency in MS Office Outlook, Word, Excel and PowerPoint and Windows 7 with the ability to learn new and complex computer systems

Healthcare Senior Claims Examiner Resume Examples & Samples

Compliance with state, federal and contractual requirements to Claims Administration
Performance standards of 15 claims/hour with 97% or above financial and procedural quality & accuracy rates
Demonstrate a thorough knowledge of the Plan's claims processing procedures as provided in training materials and proficiency with the core and ancillary system applications
Complete all mandatory claims training/refresher courses

Casualty Claims Examiner Resume Examples & Samples

Obtaining and analyzing large loss details
Developing a comprehensive strategy to efficiently and accurately reach resolution on claims presented for coverage
Conducting full investigations utilizing investigation tools and processes
Partnering with SIU to identify red flags, referral criteria and referral guidelines
Investigating coverage and liability issues unique to casualty auto policies and claims
Collaborating effectively with Homeowners to obtain required information
Providing support to team members as part of claims rotation requirements
Seven years or more experience as a Claims Adjuster
Completion of a professional designation in the insurance field
Must have completed state licensing requirements
Education equivalent to a college degree or the equivalent in related work experience with solid PC and keyboard skills, including updating and maintaining Excel spreadsheets
Must be able to effectively negotiate settlement related information to insureds, claimants, attorneys, body shop personnel, medical providers and other parties when needed
Occasional travel to attend mediation sessions and conferences

Medical Claims Examiner Qualcare Resume Examples & Samples

1-2 years of experience processing and adjudicating medical claims experience independently reviewing simple to moderately complex claims for adjudication purposes
Excellent knowledge and application of Claims Processing Systems, HSP System (Meditrac and Uniflow) preferred
Proficiency in MS Word and Excel

Claims Examiner Resume Examples & Samples

Strong organizational and customer service skills
High level of accuracy, attention to detail and strong analytical skills
Strong research and problem-solving skills
Minimum of two years prior phone/customer service and office experience
Previous experience in a Claims service environment preferred
Medical terminology/medical office background desirable
Bilingual a plus but not required

Claims Examiner Resume Examples & Samples

Updates system notes on the status of the life claim
Performs manual calculations on some claims
Processes incontestable life claims when all required documentation is received
Performs follow-up on incontestable life claims
Records production data and must meet the production quota set by the department
Must be pc/Windows literate and posses a working knowledge of MS Office (Outlook, Excel and Word)
Data entry and 10-key skills by touch and sight
Must have a strong working knowledge of medical terminology

Claims Examiner, Medical Resume Examples & Samples

Timely and accurate adjudication of all types of claims from assigned workflow queues
Demonstrates the ability to think analytically to resolve complicated claim issues and identify appropriately when to escalate issues for review
Effectively communicates with members and providers verbally and in writing regarding claim issues including claim adjudication, subrogation, and overpayments or billing problems

Claims Examiner Resume Examples & Samples

Investigate (field or otherwise) all injuries, determine compensability of the claim, evaluate liability/exposure, identify and pursue subrogation and/or salvage and prepare proper reports as required usually accomplished by performing LIDRA or three-point contact with Claimant, Facility Manager and Physician
The Workers’ Compensation Examiner II must manage medical treatment, medical utilization, authorize, control and process bills within guidelines by using cost containment program; audit provider bills
Work with injured workers, facility managers and physicians to aid in the return to full or modified work duties
Ability to recognize and manage the vocational rehabilitation process
Manage the litigation process
Develop settlement and negotiation strategies and pursue with attorneys and injured parties, execute settlement and/or release documents and issue settlement benefits as approved by settlement, courts or the WC boards
Attend appropriate ADR conferences
Determine need for and direct defense counsel, independent examiners, or other experts and monitor and control their costs
The Workers’ Compensation Examiner II must ensure all WC filings are timely, handle WC administrative inquiries, and attend WC board hearings as necessary
Communicate and interact with facility managers, injured parties, attorneys, investigators, witnesses, physicians, vendors, WC boards, etc., as needed
Interact with Division and Corporate Departments to obtain information necessary to resolve claims, discuss safety awareness and understand contractual issues presented to the company
Keep facility managers and appropriate risk management department personnel advised of file status
Prepare excess reporting as required
Ensure accurate coding of data within the claims system
Minimum of three (3) years of workers compensation claims experience
Knowledge of the applicable insurance system principles, statutes and judicial protocol. (Benefit calculation, compensability decision time line factors, sub-rosa, etc. for workers compensation including knowledge of OSHA, state reporting requirements, permanent disability systems and calculations)
Ability to organize, prioritize and complete multiple objectives
Claims system coding and use
Capable of dealing with demanding customer

Life Claims Examiner Resume Examples & Samples

Knowledge and experience with Life Claims handling
Experience with Microsoft Office Products
Excellent communication skills, analytical skills and People management experience
Drive superior claims results for low to high complexity and exposure, by providing direction, technical guidance, and tracking and reporting on key metrics
Recommend, develop and coordinate the preparation and implementation of new or revised procedures and practices to assist in the most effective accomplishment of Life Claims objectives
Approve claims within limits of authority
Track department authority levels and assess internal control efficiencies
Maintain department and individual production standards
Evaluate proficiency, maintenance of standards, reporting and takes corrective action as needed
Review claim files to ensure compliance with company procedures and reporting, regulatory and statutory requirements
Consult with Examiners on contestable life claims recommended for payment/denials
Review and recommend courses of action on claims administration matters for procedural changes, Department of Insurance matters and complaints
Counsel Life Claims staff on changes, practices and procedures needed to maintain compliance with regulatory/statutory changes, legal recommendations and best practices
Review claims involving complex investigative considerations and evaluates/trains examiners for referral to the Special Investigative Unit when appropriate
Evaluate and provide feedback to Manager on claims practices and procedures in order to strengthen operational controls and monitoring
Develop, recommend and implement workload standards to ensure efficient and effective processing
Lead special projects and perform other duties as assigned
Achieve customer satisfaction targets by building and maintaining relationships with internal colleagues, external customers and brokers, and analyzing and resolving quality and customer service problems
Achieve best practices by reviewing claims files, identifying trends and recommending improvements
Manage corporate expenses by monitoring investigation expenses, resources and other expenditures to ensure appropriateness
Ensure compliance with all legal, regulatory and internal control requirements
Provide claims insights to assist business units by collaborating in product development, customer/broker stewardship meetings
Motivate and lead a high performance team by attracting, onboarding, recruiting and retaining team members
Drive the performance management process by communicating job expectations, monitoring and evaluating performance, providing feedback and facilitating employee development per the company’s policies
Maintain transparent communication by appropriately communicating organization information to team through department meetings, one-on-one meetings, appropriate email, IM and regular interpersonal communications
Create a workplace culture that is consistent with the Zurich mission, vision and Zurich Basics
Protect Zurich´s reputation by keeping claims information confidential
Maintain professional and technical knowledge by attending educational workshops, professional publications, establishing personal networks, and participating in professional societies
Contribute to the team effort by accomplishing related results and participating on projects as needed
Oversee the operational workload of team of Life Claims Professionals; ensuring resources are fully utilized to deliver against agreed upon service levels and state mandated timelines
Monitor and review the performance and behavior of team members and take action to ensure a high performance culture, compliance with the company´s policies and codes of conduct
Regularly communicate organizational updates to team to ensure awareness and alignment with strategy and business priorities and foster employee engagement
Provide advisory services to colleagues on a daily basis, by being focal point of contact, to ensure adherence to the company´s policies and processes
Build and measure success against customer specific claims handling protocol and/or customer proposition charter to fulfill the needs and expectations of our customers
Build relationships with key customers in order to drive customer satisfaction
Build relationships with internal and external business partners and vendors in order to drive customer satisfaction
Contribute to the development of processes and lead the implementation of systems and process improvements which drive consistency and continuous improvement across own area of claims
Oversee change within area of claims, ensuring different initiatives across the organization are aligned to business goals and are delivered successfully
Translate claims objectives into clearly defined actions and behavior expectations in order to deliver results for the organization
Investigate and review escalated customer cases and represent the organization in contentious cases to ensure a speedy resolution in accordance with regulatory requirements and company policies
Ensure that appropriate documentation, implementation and communication of established policy, procedures and operating standards is completed for area of responsibility to ensure compliance, quality and consistency
Advise subordinate and stakeholders in area of specialism to raise issues as soon as possible and develop team’s capabilities
Manage and coach a team of employees to set goals and achieve results
Recruit and select employees to join team and determine when team members should be retained
Manage performance of team members, including ensuring team members comply with company policies and expectations and take appropriate action
Establish objectives and set priorities for direct reports
Assess performance of direct reports at mid-year and year-end and ensure direct reports have meaningful on-boarding, individual development plans (IDPs) and development actions
Provide regular, actionable coaching and feedback to employees to review progress, recognize accomplishments, support development and/or improve performance

Claims Examiner Resume Examples & Samples

Quality Standard - Meet and Maintain the quality rate
Claims Adjudication - Meet and consistently maintain production standards
Teamwork - Rating is based upon individual contribution to both the group and the goals of the group. This area will be rated using the outcome of team goals
Support all Departmental Initiatives in improving overall efficiency
Support Supervisors/Manager with Reports, Special Processes, etc
Overall performance accountability (attendance, communication, flexibility, adaptability, interpersonal skills, teamwork and cooperation)
General knowledge of PC usage
Good verbal & written communication
3 - 5 years of claims processing
Experience in processing of HCFA 1500, Outpatient/Inpatient UB92, Universal Claim Form

Claims Examiner Resume Examples & Samples

Quality Standard - Must meet and maintain the quality rate
Claims Adjudication - Must meet and consistently maintain production standards
1 year claims processing experience in a payer environment

Commercial Claims Examiner Resume Examples & Samples

5 or more years related claims experience required
Appropriately licensed and/or certified in all states in which claims are being handled
Extensive knowledge of accepted industry standards and practices
Computer experience with related claims and business software
Assume responsibility for all Section 1 and Section 2 type claims and management of vendor services to control cost
Promptly and effectively handles to conclusion all assigned claims with minor direction and oversight. Make decisions with delegated authority as outlined in company policies and procedures. Adheres to high standards of professional conduct consistent with the delivery or superior service
Review facts of loss and determine details of coverage via the computer system. Exam claim form, policies and endorsements
Determine investigative needs to assess damages, cause of loss, and coverage. Order police reports, fire reports, determine scope of coverage, etc. document claim file with results of review and intentions for handling. Appropriate reserving action in accordance with corporate practices
Personally contact relevant parties, where possible. Take recorded statement. Explain claims process and coverages. Begin investigation and identify SIU indicators, etc. Document claim file
Personally conduct field investigations, unless independent adjuster assignment is deemed in the best interest of the customer and the company. Assess salvage/subrogation potential and monitor to conclusion. Complete risk evaluation for underwriting and claims purposes. Document claim file
Quality assurance of field report (including estimate and other documentation, etc.). Document claim file
Deliver a positive on your side customer service experience to all internal, external, current and prospective nationwide customers

Claims Examiner Assistant Resume Examples & Samples

Ensures the accuracy and completeness of submitted claims
Processes assigned highly routine claims for payment or denial in accordance with established procedures and guidelines, in a timely manner and meeting departmental quality/production standards
Recognizes general issues/concerns for assigned area(s) of responsibility, explains effect on the customer's service experience, and suggests process improvements
Reviews submitted claim information for payment

Legal Administrative Specialist Senior Msp Claims Examiner Resume Examples & Samples

Click the Submit My Answers button to submit your application package. It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date
Knowledge of the laws, regulations, policies and procedures of health benefits claims
Oral Communication
Written Communication
A Resume showing relevant experience; (cover letter optional). Your resume must show the work schedule and hours worked per week as well as dates of employment
Current OPM Employees, a copy of your most recent Notification of Personnel Action (SF-50 or equivalent) showing that you are in the competitive service (1 in block 34), as well as the highest grade (or promotion potential) held, on a permanent basis. This SF-50 must show that you are CURRENTLY an Office of Personnel Management employee
CTAP/ICTAP Reduction-In-Force: Certification of Expected Separation, Reduction-In-Force Separation Notice, or Notice of Proposed Removal; AND most recent performance evaluation; AND SF-50 documenting your separation or the position you will be separated from
Land Management Eligibles: a copy of your most recent Notification of Personnel Action (SF-50 or equivalent) proving your eligibility for appointment under the Land Management Workforce Flexibility Act. This service must have been performed in the competitive service, under a time limited appointment in a Land Management Agency, as defined by P.L. 114-47. For more information, click here

Claims Examiner Resume Examples & Samples

Interpret various policies and correctly determine if benefits are to be paid or denied while consistently maintaining quality and quantity standards
High School diploma or equivalent work experience
One year of disability/accident claims processing experience
Proficiency in MS Office (Word, Excel, Outlook)
Skilled in 10-key
Experience using CK4, AWD, ENCORR and Claims Mantis systems
Knowledge of state insurance laws and regulations

Claims Examiner, Beneficiary Services Resume Examples & Samples

Reviews claims and extracts information for processing
Collects and processes death and life disability waiver claims
Verifies, corrects and completes claims information by telephone, letter or personal contact
Calculates benefits payable; approves (to a specified amount) or denies claims in accordance with established procedures
Work experience in the life insurance industry a plus
Ability to exercise sound judgment and risk assessment during claim adjudication
High level of flexibility to adapt to the needs of the team, division/organization

Claims Examiner Resume Examples & Samples

Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment and requests for claim adjustments or to requests from outside agencies
Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error
Identifies potential provider problems through a proactive approach in which data is mined and trended to identify and prevent provider problem areas
Uses a variety of references to research and prepare healthcare provider information for loading into the health plan system/database; enters provider demographics, contract affiliation, or other data as needed
Interfaces with other departments regarding questions about provider configuration or other relevant provider issues
Composes all correspondence and appeal information concisely and accurately, in accordance with regulatory requirements
Maintains tracking system of correspondence and outcomes; maintains well-organized, accurate and complete files for all appeals
Monitors each request to ensure all internal and regulatory timelines are met
3 years experience in a managed care setting; CPT and ICD-9 coding, data entry, and 10-Key experience
4+ years managed care experience

Claims Examiner Resume Examples & Samples

2+ years of experience in the Healthcare Insurance industry
Associate's Degree in a related field
Knowledge of Integrated Claims processing
Thorough knowledge of Medical terminology, CPT, ICD-p and Revenue Codes
Solid data entry skills

PD Claims Examiner Resume Examples & Samples

Maintain a pending of comprehensive/collision, property damage and subrogation/arbitration claims within their authority
Diary maintenance and adjust reserves within assigned authority
Communicate effectively with customers and fellow employees to solve any problems that may arise and come to an amicable resolution to the situation
Make strong liability decisions based on the facts of the loss and document clearly their thought process within their authority
Determine coverage confirmation, remain alert to identify coverage inconsistencies and work with Underwriting to clarify and resolve
Identify any possible fraudulent claims and refer to Investigative Unit
Answer Arbitration Forums contentions
Review Appraisals and Total Loss valuations for accuracy
Produce thorough and consistent work

Senior Claims Examiner Resume Examples & Samples

Serve as a liaison between the OSGLI and the Group Insurance Law Department and Special Investigations Unit (SIU)
Serve as Complaint/Congressional Inquiry coordinator
Serve as technical advisor to all OSGLI staff
Serve as back up to team leadership
Handle complex claims (i.e. competing claims, beneficiary involvement, Law referrals)
Manage aged claims for efficient resolution
Prepare answers to interrogatories, responses to subpoena and document requests, and affidavits on claims and on active policies
Assist with preparation of training material and conduct training for new claim employees
Review/approval of claim payments above the Claim Examiners authority limit
Conducts claim management reviews of claim cases
Handling escalated customer/claim calls
Assist in monitoring the section’s workflow
Process claim payments when necessary
Possess the flexibility to perform other duties as assigned
Prior claims handling experience desired
Prior group life claims experience preferred (3-5 years)
Strong issue identification and problem solving skills
Ability to prepare replies to complex/congressional claim inquiries
Proven self-motivation skills
Close attention to detail a must
Ability to work from home when needed. Upon the successful completion of training and a period of time of meeting all operational metrics, an alternate work schedule is possible

Claims Examiner Resume Examples & Samples

Process decisions on claims through claim management system (LCMS) and/or new business application (Compass)
Approve and deny claim payments within authorization limits
Render decisions on disability extension requests and traumatic injury claims within authorization limits
Correspond with claimants, law department, underwriting, Casualty Assistance Officers, attorneys, the Veterans Administration and other interested parties through the life of a claim
Bachelor's degree, or equivalent military experience, preferred
Ability to analyze data on claims and make appropriate claim decisions

Claims Examiner Resume Examples & Samples

Under close supervision and guidance, adjudicate a caseload of construction defect claims within narrowly defined limits and authority
With oversight, compose coverage position letters including disclaimers and ROR’s covering single and multiple policy years
Investigate claims promptly and thoroughly
With oversight, manage claims in litigation
Properly set claim reserves
Identify, assign, and coordinate the assignment and coordination of expertise resources to assist in case resolution
Prepare reports for file documentation
Applying creative solutions which result in the best financial outcome
Negotiate settlements,
Responsible for telephone calls and written correspondence to/from various parties (insured, claimant, etc.)
Prior related work experience required in general liability claims handling involving property damage or bodily injury claims (generally three years prior experience) with a desire to learn construction defect claims handling, including residential and large commercial structures, with some experience in litigation management
Ability to prioritize workload and handle multiple tasks
Exhibit a natural curiosity
Desire to work in a fast paced environment
Strong claim negotiation skills a must
Must possess a strong customer focus
Proficient in MS Office Suite and other business-related software
Polished and professional written and verbal communication skills

Senior Claims Examiner Resume Examples & Samples

Analyze coverage on commercial auto and garage policies
Evaluate and resolve total losses of autos
Investigate, evaluate, and settle claims
Work closely with the underwriting department to assist with risk evaluation
Maintain professional licensure to settle claims as required
Bachelor’s degree or three year to five years related insurance experience and/or equivalent combination of education and experience
Minimum of 5 years claims experience handling commercial auto claims
Demonstrated analytical skill in the review and evaluation of underwriting and policy documents
Excellent oral/written communication and decision making skills
Previous insurance educational work, IIA and CPCU desired
Must be license eligible to settle claims in required states
Proficient in the use of computer programs, including Word, Excel, and Outlook

Senior Claims Examiner Resume Examples & Samples

Adjudicating a caseload of construction defect claims with high degrees of complexity
Analyze claim forms, policies and endorsements, client instructions and other records to determine whether the loss falls within the policy coverage
Compose coverage position letters including disclaimers and ROR’s covering single and multiple policy years
Interview involved parties
Work with general contractor and sub-contractor insurance carriers to efficiently and timely bring matters to a conclusion
Manage claims in litigation
Manage diary timely and complete tasks to ensure that cases move to the best financial outcome and timely resolution
Negotiate settlements
Processing mail and prioritizing workload
Have an appreciation and passion for strong claim management
Must have good business acumen (i.e. understand how an insurance company works and makes money, including how this role impacts both Argo Group and our customers’ ability to be profitable)
Bachelors degree strongly preferred
Prior related work experience required in construction defect claims handling, including residential and large commercial structures, with experience in litigation management of complex matters sufficient to be able to exercise discretion and independent judgment in order to manage a caseload with only limited oversight by a manager (generally ten or more years)
Ability to articulate the financial value of your work at multiple responsibility levels inside our clients’ business which may include the CEO
Excellent evaluation and strategic skills required
Must work independently and demonstrate the ability to exercise sound judgment
Ability to travel, often overnight, approximately 20% of the time
The ability to read and write English fluently is required. The ability to read and write Spanish fluently is considered a plus but not required
Must demonstrate a desire for continued professional development through continuing education and self-development opportunities

Associate Claims Examiner Resume Examples & Samples

Reviews, verifies, and confirms claims
Verifies that the cession claimed on was properly ceded to RGA Re and was properly established on RGA Re administration system
Takes all initial steps to resolve questions that arise from the above action
Makes corrections within accepted parameters and escalates unresolved discrepancies to supervisor
Calculates interest and/or expense to ensure accuracy
Contacts other RGA Re associates or clients to help resolve/correct data discrepancies
Processes payment for approved claims via ACH, wire transfers or check
May assist in training of new or junior associates
Recognizes early death claims to be escalated
Maintains regular and predictable attendance
Associate’s degree or equivalent work experience in insurance, reinsurance or Financial services
0-2 years claims experience
Basic Microsoft Word Skills
Basic Microsoft Excel Skills
Basic Microsoft Outlook Skills
Basic written and oral communication skills
Must be flexible and adaptive to change
Takes initiative and is accountable
Ability to prioritize assigned work

Accident / DI Claims Examiner Resume Examples & Samples

Apply various state laws and regulations when processing claims
Process disability claims, calculate and offset benefits, initiate repetitive payments and waiver of premiums, as applicable
Respond to customer service questions

Claims Examiner Resume Examples & Samples

40% General Claim Events: Support the business by processing general claim events, including but not limited to
Processing general claim events
Responsible for following claim event procedures and processes
Responsible for investigating, analyzing, and understanding the risk with paying claim events to Funeral Homes, beneficiaries, unclaimed property, and third parties
50% Phone Calls: Support the achievement of the team through outbound and inbound phone calls regarding claim events
Make outbound calls to customers regarding pending claim events
Receive inbound calls from customers regarding claim events
10% Special assignments and projects as assigned
Note: This position requires continued education regarding insurance and claims that is paid for by the company, but the responsibility of the employee to complete every 6-12 months
GED or High School Diploma
Experience in insurance (life or health) – 1 year
Customer Service Experience in office environment – 1 year

Claims Examiner Resume Examples & Samples

Adjudicate claims in accordance with departmental policies and procedures and other rules applicable to specialty claims
Maintain average production standards of 100-150 Hospital claims and 200-250 Professional claims per day established by claims management
Work with management to monitor and upgrade database and resource materials
Provide backup for other examiners within the Department

National Claims Examiner Resume Examples & Samples

Must maintain current adjuster licenses in assigned states
Ability to provide technical directions and work effectively with staff at all levels
Must have basic ability to set up and maintain Excel for communication, reporting and documentation purposes

100

Complex Claims Examiner Resume Examples & Samples

Functional Responsibilities
Utilizing acceptable investigation claims handling and settlement techniques that achieve cost effective and timely closure results by obtaining, reviewing and analyzing documentation, policy provisions and other records
May require additional contact with other parties (i.e. employer, claimants, third parties such as builders etc. as deemed necessary
Utilizes diary system to pro-actively resolve outstanding issues and to ensure timely processing and closure of claim
Providing timely service throughout the life of the claim by meeting all service level agreements, initiating timely contact to all appropriate parties, and responding to incoming inquires according to company policy and procedures
Maintaining accurate system data and documentation by collecting, recording, analyzing, and summarizing information
Determining and timely sets appropriate reserves within authority level
Providing mentorship to less tenured examinerStriving for continuous improvement on claim file handling with feedback and support through the Quality Assurance Review processes
Contributing to maintenance of best practice procedures for (LOB) claims, consistent with global best practiceDemonstrating a basic standard of technical claims competence for handling lower complexity claims
Handling claims allocated within agreed level of authority limit
Timely, accurate and customer focused claim resolution, minimising indemnity exposure and mitigating vendor and legal expense
Consistent proactive claims handling on an ongoing basis (i.e. initial file review, investigations and liability, negotiations and settlement, and litigation management)
Effective communication of key claims and (LOB) portfolio messages to internal stakeholdersFinancial control through consistent reserve and other financial transaction disciplineAccurate and consistent policy interpretation
Experience in dealing with business pack, residential and/or commercial strata claims including loss of rents matters is essential
Ability in the interpretation and application of policy wordings
Experience adjusting lower level complexity claims
Ability to prioritize and multi-task effectively in a fast paced environment
Ability to communicate information clearly and concisely both verbally and in writing
Requires proficiency in Desk Management, phone ‘etiquette’ , time management and dealing with difficult customers
Experience with claim negotiations and interpersonal flexibility is a necessity
Experience in the appointment and management of various stakeholders including loss adjusters, lawyers and other experts

101

Complex Claims Examiner, Financial Lines Resume Examples & Samples

Managing claims handling enquiries, coverage determinations, quantum analysis and legal liability assessments
Ensuring effective vendor and litigation management on Complex claims, including demonstrable savings
Reporting key claims outcomes to the Australasian Complex Claims Manager and to internal stakeholders
Broadening internal / external stakeholder communication where required, as financial lines technical claims expert and thought leader
Assisting in continuous improvement across the region through support for the Quality Assurance / Regional Audit processes (including
Timely, accurate and customer focused claim resolution, minimizing indemnity exposure and mitigating vendor and legal expense
Consistent proactive claims handling on an ongoing basis (i.e. initial file review, investigations and liability, negotiations and settlement, and panel firm management)
Effective communication and management of key complex claims and financial lines portfolio messages to internal stakeholders and customers/clients
In addition, the successful applicant will be required to
Work within agreed decision making standards, limitations and authorities
Comply with key regulatory and risk management responsibilities
Carry out your accountabilities and objectives within the framework of AIG Australia’s Regulatory policy
Legal or other tertiary qualifications preferred however candidates with good industry experience will be considered
Good presentation skills and portfolio knowledge
Ability to manage and prioritise workload and diary management
Ability to contribute effectively within a team environment and with internal/external stakeholders at all levels
Ability to assist with technical training to claims team as required
Well developed/advanced expertise and knowledge in financial lines technically complex claims
An advanced and thorough knowledge of legal / regulatory and litigation / procedural requirements for financial lines
Experience in negotiation, mediation, arbitration and ADR skills on higher value claims
Experience in effectively following up on recommendations from technical claims audits and continuous file handling improvement

102

Facility Claims Examiner Resume Examples & Samples

2 or more years HMO claims processing experience required in a managed care environment, preferably PMG/IPA setting within the last three years or any combination of education and/or experience which produces an equivalency
Extensive knowledge of medical terminology, CPT, ICDA-9 and RVS codes
Solid working knowledge of insurances -- PPO, EPO, HMO, POS, Medicare, etc., plus extensive working knowledge HMO claims processing
Proficient use of CRT keyboard, 10-key adding machine and make mathematical calculations
Must possess excellent oral and written communication, and computer skills in a mainframe setting
Must display a high level of flexibility and attention to detail
To exceed or be an outstanding producer, productivity should be greater or equal to 200 claims per day with no more than a 2% error rate
Knowledge of Microsoft Office (i.e., Excel, Microsoft Word, etc.) a plus

103

Senior Claims Examiner Resume Examples & Samples

The Sr. Claims Examiner will be responsible for reviewing and processing Annuity Death Claims, surrenders and withdrawals in the Claims Department for Oxford Life Insurance Company. The Sr. Claims Examiner will be required to learn company plans, along with systems, and be able to provide outstanding service to satisfy members’ needs
Responsibilities include but are not limited to
Paying benefits
Taking and making customer service calls with policyholders and agents
Adjudicating all medical claims
Performing pre-existing investigations
Managing tax implications within the administration software in compliance with mandated insurance laws
Streamlining and documenting all transaction processing functions
Creating reports and routine procedures to effectively administer policies
Working with business analysts to improve efficiency of administration software
Communicating with other department heads

104

Complex Claims Examiner, Personal Lines Resume Examples & Samples

To handle Personal Lines – Home, Contents and Auto (LOB) portfolio of claims from coverage enquiry through to quantum analysis, to timely and accurate resolution; ensuring mitigation of indemnity and expense exposure while communicating developments and outcomes as necessary to all key internal and external stakeholders
To provide training and be a technical referral point for others
Stakeholder management including scheme/affinity partners and third party claims administrators
May also include cross-border claims handling, including awareness of legal and regulatory systems outside "home" jurisdiction
Managing key complex claims handling enquiry; coverage determination, quantum analysis and legal liability assessment, where appropriate within authority limits and providing a high standard of customer service
Ensuring effective vendor and litigation management
Developing communication for internal and external stakeholders, where required
Striving for continuous improvement on claim file handling with feedback and support through the Quality Assurance Review processes including undertaking Quality Assurance Reviews
Contributing to maintenance of best practice procedures for Complex claims, consistent with global best practice
Demonstrating a high standard of technical claims competence for handling moderate to high complex claims
Handling complex claims allocated within agreed level of authority limit
Establishing, reviewing and refining effective claims handling processes
Reviewing and responding to claim technical referrals
Accountabilities
Stakeholder management and oversight including scheme partners and third party claims administrators
Line of business specialist knowledge
Personal Lines – Home Building, Contents, Landlord and Auto
Excellent communication skills, both written & verbal
Time management – ability to manage & prioritise workload and diary management
Ability to assist with technical training to team claim handlers as required
Ability to influence claims and non-claims stakeholders to effectively direct claims strategy
Well-developed/Advanced expertise and knowledge Personal Lines most technically complex claims topics
An advanced and thorough knowledge of legal / regulatory and litigation / procedural requirements for their line of business
Experience in negotiation, mediation, arbitration and ADR skills on higher value complex claims
Experience in the development and implementation of claims process and procedures including continuous improvement activities

105

Claims Examiner Workers Compensation Resume Examples & Samples

Negotiates settlement of claims within designated authority
Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets
Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business

106

Claims Examiner Resume Examples & Samples

Analyzes and manages first party property, casualty and/or medical reimbursement claims based on multiple/additional coverage and/or programs as defined by client-specific program
Makes coverage determinations based on investigation/evaluation and communicates claim actions with claimant and client
Adjudicates proper settlements up to designated authority level
Works directly with underwriter/client on high value complex cases
Handles high volume of claims, phone calls and correspondence ensuring claim files are properly documented; and meets quality/production goals and customer guidelines and deadlines
Communicates claim activity process with client and claimant as appropriate
Assists with assignment of daily workflow in the department and client data tracking system
Assists with coaching, training and deployment of changes in client instructions

107

Workers Comp-claims Examiner Resume Examples & Samples

Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution
Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim
Prepares necessary state fillings within statutory limits
Manages the litigation process; ensures timely and cost effective claims resolution

108

Senior PW Claims Examiner Resume Examples & Samples

Oversee small to medium technology projects and/or phases of projects
Review business needs, translate into business specifications, and manage projects through testing and deployment
Represent area in system enhancements and design activities
Provide updates to business leadership regarding project status and the application and implementation of technology
Determine specific business application requirements to address varied business needs and analyses and designs solutions to meet those needs
Monitor the progress of initiatives and milestones to ensure timeliness and deliverables are met
Manage critical relationships with Vendor, IT, Consultants, internal end users, and business customers/leadership
Provide information to end users to help resolve problems as well as develop detailed work plans, schedules, project estimates, resource plans, and status reports
Interpret policy provisions to determine eligibility and make claim determinations
Initiate investigations through both company and external contacts (i.e., employees, employers and physicians) to obtain medical and vocational evidence required for approval of claim
Establish action plans for each file to bring claim to resolution
Actively pursue and follow up on open claims within specified timeframes
Utilize Intellis, UDS and ACS systems to update and maintain accurate data records
Utilize internal specialty resources to maximize impact on each file
Coach new hire Premium Waiver Claim Examiners on procedures and workflow
Manage and organize work to meet multiple deadlines and competing priorities to ensure department turnaround and customer satisfaction are met
Interaction with LTD Case Managers on companion PW and Disability cases and Life Examiners on all deaths of PW applicants
Life and/or Disability insurance experience
Analytical ability and good judgment in evaluating claims
Ability to build a simplified message from complex data
Intermediate to advanced knowledge of Access, SQL, relational database architecture, or other relevant query tools
Technical Documentation: System Interface Specifications, Business writing skills

109

Claims Examiner Resume Examples & Samples

Investigate all injuries, determine compensability of the claim, evaluate liability/ exposure, identify and pursue subrogation and /or salvage and prepare proper reports as required
Manage medical treatment, medical utilization, authorize, control and process bills within guidelines by using cost containment program; audit provider bills
Provide timely and accurate benefits to the legitimately injured worker
Perform three-point contact with Injured Worker, facility Manager and Physician
Evaluate and maintain timely claim reserves
Interact with Divisions and Corporate Departments to obtain information necessary to resolve claims, discuss safety awareness and understand contractual issues presented to the company
Minimum of one (1) year workers compensation claims experience
Knowledge of the States Workers” Compensation system principles, statutes and judicial protocol (benefit calculation, compensability decision time line factors, subrosa)
Ability to organize, prioritizes, and complete multiple objectives
Proficient reading skills

110

Life Claims Examiner Resume Examples & Samples

Juris Doctor and 5 or more years of experience in the Claims area
Experience collaborating across work groups
Knowledge of insurance legal statutes and procedures
Knowledge of the insurance industry, claims and the insurance legal and regulatory environment

111

Claims Examiner Resume Examples & Samples

Authorize, appropriate payment or refer claims to investigators for further review
Accurately process professional claims
Responsible for editing and adjusting of claims
Analyze and adjudicate claims to ensure accurate payment
Interpret Fee for Service (FFS) and capitated provider contracts
Review claims on a periodic basis
Meet Department Quality and Accuracy Standards
Interfaces with other departments to obtain necessary information required for resolution of claims
Advise management of any claim issues or inappropriate and/or incorrect billing
Other duties assigned by management
High School diploma or GED OR 10 years of equivalent working experience
4+ years of experience analyzing and solving customer problems in an office setting environment using the telephone and computer as the primary instruments to perform job duties
Moderate proficiency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications
Ability to multi-task, this includes the ability to understand multiple products and multiple levels of benefits within each product

112

Claims Examiner Resume Examples & Samples

Behavior questionnaires
Data entry alphanumeric testing
Other skill assessments

113

DOJ Claims Examiner Resume Examples & Samples

Two years of full-time experience determining eligibility for benefits and/or verifying, validating, analyzing, and/or evaluating information such as police reports, medical and psychological assessments, treatment plans, diagnosis and outcomes, income and tax records, and/or insurance plans
Experience working an ongoing caseload
Experience communicating decisions, rules, regulations, policies, and procedures to clients from diverse social and economical backgrounds, verbally and in writing
Experience writing comprehensive reports
Experience providing services to vulnerable populations
Exceptional organizational, prioritization and multi-tasking skills
Experience compiling and evaluating facts to determine eligibility or compliance with program guidelines

114

Claims Examiner Resume Examples & Samples

Research, interpret and calculate benefits according to contractual provisions, federal and state regulations and current procedures
Review benefit paperwork for accuracy and completeness
Verify and update plan participant records
Consistently meet quality and productivity standards
Build relationships with other business partners
May participate in special projects as needed
BS Degree or minimum of 1-2 years equivalent work experience
Flexibility to work overtime, when required

115

COB Claims Examiner Resume Examples & Samples

JEPS Math (Coordinated with recruiter during the interview process)
The ability to make judgments regarding covered services and to resolve complex coverage issues as demonstrated by
2) two-years work experience as a claims examiner independently analyzing and processing nonroutine complex medical claims at another employer
Must possess keyboard skills
Keystroke competency and 10-key skills
Demonstrate independent analytical problem-solving skill
Examine claim forms, electronic claims and other records to verify Plan coverage and determine if other insurance coverage is applicable
Assign appropriate coding as necessary to determine benefits
Determine benefit coverage through interpretation of plan provisions, policies and procedures, including coordination of benefits
Make judgements regarding covered services through a review of patient history and the appropriate application of plan policies and procedures
Respond to member correspondence / telephone inquiries submitted through the member services area regarding claim adjudication and determinations
Perform adjustments to previously processed claims as required to correct payment detail or online information. This includes all overpayment and underpayment claims
Perform other duties as assigned by HealthPartners Claims Department management

116

Veterans Claims Examiner Resume Examples & Samples

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307-17-30-1938649-MPA-BU
Experience demonstrating a working knowledge of the claims processing program related to benefits (i.e. insurance, medical/health, worker's compensation, etc.)
Experience electronically controlling and maintaining pertinent files and documents in the claims process
Explaining benefit criteria or programs, answering benefit questions and resolving problems and recommending courses of action

117

Claims Examiner TGS Resume Examples & Samples

Strong verbal and written communication is important
Dealing with Manufacturers, Warranty Providers, and clients
Punctuality and dependability a must
Must be accurate, neat and organized, and detail oriented
Proven ability to produce results, self-motivated & customer service oriented
Computer skills, telephone etiquette
Effective problem solver, team player

118

Claims Examiner Resume Examples & Samples

Data Entry and/or typing experience
Ability to multi task and prioritize is required
Social, verbal and written communication skills
Ability to sit for long periods of time

119

Workers Compensation Claims Examiner Resume Examples & Samples

Evaluates new and on-going claims to determine compensability and liability, giving consideration to contract provisions, disability management duration contract guidelines, medical evidence and vocational evidence
Investigates questionable claims
Determines needs for additional medical information
Determine appropriate benefit calculations and payments
Performs reviews to verify initial and continued existence of a disabling condition
Responds to telephone and written inquiries from claimants, attorneys, physicians and policyholders within statutory requirements
Identifies and forwards claims to specialized internal and external resources in areas such as medical exams, rehabilitation, investigations, subrogation and subsequent injury
Track time frames as mandated by statute and regulation
Respond to correspondence to include litigation compliance with decisions & orders
This level is responsible for independently reviewing simple to complex claims for adjudication purposes
Refers more complex claims to higher levels for review and direction
This level is responsible for administering simple to complex including catastrophic claims
5+ years of experience processing and adjudicating simple to complex claims
Intermediate proficiency with Microsoft Word, Microsoft Excel, Microsoft Outlook, and Letter Composition
Advanced knowledge of fundamental concepts, practices and procedures of case law and state Worker’s Compensation laws, subrogation, reserve setting, and litigation management
Intermediate experience with catastrophic claims
Intermediate experience with PPD Calculations, Interest Payments, TTD Benefit Payments, Recorded Statements and Vocational Rehabilitation

120

Claims Examiner Resume Examples & Samples

Process complex claims. Conduct research and investigation into missing Information, make phone calls to external contacts, access resource materials and support files on Blue Chip in order to process and adjudicate claims timely and accurately
Resolve complex pended claims and adjustments
Process Blue Card claims, involving communications with participating plans. Resolves various Blue Card issues
Maintain knowledge of pre-existing condition and waiting period requirements as they relate to specific contracts. Resolve error messages as they relate to pre-existing conditions
Read appropriate files in IMAGE and apply appropriate information to claims as needed using the Financial Suspense System (FSS)
Maintain files and records
Learn and maintain knowledge of DOL Erisa and prompt pay legislation
Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies
Maintain communication with management regarding developments within areas of assigned responsibilities and perform special projects as required or requested

121

Life Claims Examiner Resume Examples & Samples

Review, investigate, identify issues and develop sufficient valid evidence to make objective claim eligibility determinations
Analyze and accurately interpret group life contracts
Analyze accidental death reports for life claims, i.e., accident reports, medical examiner reports, toxicology reports
Accurately process life claim payments
Ability to interpret and correctly apply state statutory regulations and ERISA rules
Clearly and accurately communicate claim decisions to policyholders, claimants and beneficiaries
Maintain claim files in a manner defensible in court with thorough, clear and objective claim documentation
Coach policyholder on the administration of the group life and waiver of premium benefits
Provide superior customer service to internal and external customers

122

Complex Claims Examiner Resume Examples & Samples

Managing key claims handling enquiry; coverage determination, quantum analysis and legal liability assessment, where appropriate within authority limits and providing a high standard of customer service
Working with Team Manager/Senior Adjuster to ensure effective vendor and litigation management on Complex claims within a personal allocation
Developing communication for internal stakeholders, where required
Striving for continuous improvement on claim file handling with feedback and support through the Quality Assurance Review processes
Contributing to maintenance of best practice procedures for (LOB) Complex claims, consistent with global best practice
Demonstrating a basic standard of technical claims competence for handling moderate to lower complexity complex claims
Effective communication of key Complex claims and (LOB) portfolio messages to internal stakeholders
Financial control through consistent reserve and other financial transaction discipline
Accurate and consistent policy interpretation

123

Express Claims Examiner Resume Examples & Samples

Utilizing acceptable investigation claims handling and settlement techniques that achieve cost effective and timely closure results by obtaining, reviewing and analyzing documentation, policy provisions and other records. May require additional contact with other parties (i.e. employer, claimants, third parties such as medical providers, auto repair centers, etc.) as deemed necessary. Utilizes diary system to pro-actively resolve outstanding issues and to ensure timely processing and closure of claim
Identifying subrogation opportunities and fraud potential and make appropriate referrals
Providing mentorship to less tenured examiner

124

Claims Examiner Resume Examples & Samples

Process claims – review insured’s file and death claim documents to determine eligibility in accordance with the terms of the insurance contract and applicable laws
Answering calls – Customer calls from ACD line as well as communicating internally with other departments
Correspondence – Respond in writing to customer inquires
Research – research customer inquiries by reading policies, the file and reviewing the systems
Approve claims up to the approved set limits
Other job duties as assigned
Has knowledge of Windows base computer systems
Ability to learn quickly with or without benefit of written procedures
Has excellent written and oral communication skills used to negotiate solutions with customers of varying temperaments
Life insurance industry knowledge gained by completion of the first LOMA test within the first year of employment
Ability to use independent initiative to seek answers to customer concerns
Ability to plan, organize workflow, while setting goals
Ability to thrive in an ever-changing team environment
Self starter and is able to work with minimal supervision
Ability to understand multiple lines of business
Ability to read insurance policies
Ability to analyze data and make recommendation changes in the workflow
Ability to review derive answers from company historical records which can be incomplete

125

Claims Examiner Resume Examples & Samples

Two or more years HMO claims processing experience required in a managed care environment, preferably PMG/IPA setting within the last three years or any combination of education and/or experience which produces an equivalency
Ability to type 35 WPM, use a ten‑key adding machine, perform data entry and make mathematical calculations
Must also meet productivity goals of processing a minimum 120 to 160 claims per day with no more than a 2% error rate
Familiar with CMS and Dept. of Managed Health Care mandates

126

Workers Compensation Senior Claims Examiner Resume Examples & Samples

Provides quality service to all customers
Completes quality investigation by gathering all pertinent information (recorded statements, review of police and medical reports, photographs and appraisals/estimates of damages, etc.)
Determines if subrogation exists and takes steps necessary to initiate recovery efforts
Maintains appropriate financial accountabilities (reserving) and controls loss adjustment expenses
Fulfill state licensing agreements/requirements (if applicable) and apply knowledge of state laws and regulations pertaining to the insurance industry
Other tasks as assigned by supervisor/manager
Good knowledge of claim procedures, policies, technology, state and federal laws and insurance regulations

127

WC Claims Examiner Resume Examples & Samples

Good analytical abilities to review, exercise judgment and evaluate claims in order to make sound decisions
Ability to multi-task and handle large volumes of work in a short period of time
Ability to carry out detailed written or verbal instructions, ability to respond to requests effectively and efficiently and exhibit good common sense
A valid California adjusters’ license
Minimum of five years experience in workers compensation claims

128

Claims Examiner Resume Examples & Samples

Interview with claimant and witnesses as well as gather information i.e. police and hospital records, estimates to determine injuries
Conduct a thorough analysis of liability and damages
Complete quality investigations by gathering all pertinent information (recorded statements, review of police and medical reports, photographs and appraisals/estimates of damages, etc.)
Document all correspondence, reports, discussions and decisions
O College degree is not a prerequisite for this position; however employee should possess such skill and knowledge as are normally gained in the successful completion of a four-year college program

129

FEP Claims Examiner Resume Examples & Samples

Review and finalize claims referred from Data Capture for OPL, Medical Review, BGT/Coverage, payment level, and case management
On a daily basis work all system generated reports to ensure accurate claims control
Meet departmental, contractual and national performance goals
Maintain required production and accuracy standards
Be able to finalize claims for FEP, Cross, Shield, Major Medical, SRS, Dental, Drugs and MER lines of business
Identify and document system and procedural problems; provide suggestions for resolution
Finalize edits in deferrals
Requires constant and intense concentration to complete complex job functions. Work is confining and requires keying at PC up to 80% of the day
Ability to key 8,000 KPH with accuracy of 95% or greater preferred
Extensive knowledge of all product lines and ability to resolve edits and adjustments for medical review, coverage/BGT, case management, accumulators, precerts, SRS claims, Pre-dets, and some OPL activity by completion of training period
Detailed working knowledge of ACES, EIM/ESM, OTIS, CSI, Client Letter, Lotus Notes, Imaging, Trove and numerous other related systems by completion of training period
Expected to maintain low absenteeism
Adjustment rate of 2% or less required

130

Senior Fmla Claims Examiner Resume Examples & Samples

Supports and promotes change management and/or departmental/enterprise initiatives within assigned area(s) of responsibility
Communicates effectively and provides customer service at every touch point to internal/external stakeholders, recognizes what needs to be done to meet customer needs and demonstrates flexibility and responsiveness to meet customer needs on routine work independently
Educates team members and internal stakeholders on increasingly more complex delivery processes, practices and procedures for assigned area(s) of responsibilities
Ability to efficiently utilize multiple systems to record and communicate absence requests and determinations

131

Claims Examiner Resume Examples & Samples

Fully developed specialist knowledge in (LoB) technical claims topics (as listed over page)
Strong stakeholder management experience, both internal (underwriting, distribution, actuarial, finance and executive management) and external (brokers, major account clients)
Policy language skills enabling accurate and consistent policy wording interpretation
A strong knowledge of legal / regulatory and litigation / procedural requirements
Experience in negotiation, mediation, arbitration and ADR skills
Audit and Compliance
Ensure adherence to Claims best practice and compliance requirements

132

Workers Compensation Claims Examiner Resume Examples & Samples

Excellent written and verbal skills
Integration with Medicare
Prefer 5 years Claims Examiner experience; WCCA/WCCP may substitute for 2 years’ experience

133

Senior Workers Compensation Claims Examiner Resume Examples & Samples

Establishes appropriate reserve levels based on financial exposure and updates reserves upon receipt of new information
Annotates, categorizes and addresses incoming mail on a daily basis
Workers’ Compensation law; policies and procedures
5 years Claims Examiner experience; WCCA/WCCP may substitute for 2 years experience

134

Temporary Workers Compensation Claims Examiner Resume Examples & Samples

Directs assistant to properly pay indemnity benefits and Awards. Issue state-mandated benefit notices within the required timeframes
Responding to questions and requests from the client
5 years of California Public Entity experience is preferred
Safety Officer experience is a plus

135

Temporary Senior Workers Compensation Claims Examiner Resume Examples & Samples

Completes 3-point contact on new claims within 24 hours in order to obtain information necessary to make a compensability decision on the claim
Directs assistant to properly pay indemnity benefits payments and Awards. Issue state-mandated benefit notices within the required timeframes
Strong litigation skills, highly efficient with excellent customer service skills
Medical and legal terminology

136

Future Medical Claims Examiner Resume Examples & Samples

Payment of benefits where applicable (Life pension, PD, medical bills and medical mileage reimbursement) (15%)
Diary compliance (new mail & CMR’s), verify, analyze and appropriately establish reserves based on lifetime exposure. (40%)
Provide verbal and written communication with our injured workers and clients
Adherence to client protocls as well as York operating definitions
Strong technical skills
Ability to anticipate and resolve issues proactively and in a professional manner
1 to 3 years in a Claims Assistant role preferred

137

Claims Examiner Resume Examples & Samples

High school diploma, GED Certificate or equivalent
Minimum of one year of related experience. Experience with or certification in QicLink preferred
Knowledge of medical terminology including CPT-4, ICD-9, ICD-10, HCPCS, ASA and UB92 Codes, and standard of billing guidelines
Limited travel

138

Claims Examiner Resume Examples & Samples

Resolve outstanding holds in accordance with designated standards
Maintain employee/insured confidentiality. Participate in training programs as requested
Identify areas of concern that may compromise client satisfaction
Openly participate in team meetings, provide ideas and suggestions to ensure client satisfaction, and promote teamwork
Maintain mail date integrity
Assist other departments during periods of backlogs
Process MCNet batches by resolving various claim errors in accordance with designated standards
Overtime may be required as per business need
High school graduate or equivalent required
One year of claims processing and/or equivalent education preferred
Knowledge of medical terminology, ICD-9, and CPT coding required
Knowledge of commercial, Medicaid, and Medicare products
Ability to use a QWERTY keyboard
Competent in MS Office and PC skills preferred
Working knowledge of COB (Coordination of Benefits) preferred
Ability to demonstrate organizational, interpersonal, and communication skills
Maintain designated production and quality standards required

139

Claims Examiner Resume Examples & Samples

Processes complex auto commercial and personal line property claims and ensures claim files are properly documented and coded correctly
Responsible for litigation process on litigatedclaims
Coordinates vendor management, including the use of independent adjusters to assist the investigation of claims
Reports large claims to excess carrier(s)
Develops and maintains action plans to ensure state required contact deadlines are met and to move the file towards prompt and appropriate resolution
Identifies and pursues subrogation opportunities; secures and disposes of salvage
Communicates claim action/processing with insured, client, and agent or broker when appropriate
In-depth knowledge of personal and commercial line property policies, coverages, principles, and laws
Knowledge of construction basics and property estimating software Excellent oral and written communication, including presentation skills
Knowledge of appropriate application of deductibles and sub-limits
Strong oral and written communication, including presentation skills

140

Premium Waiver Claims Examiner Resume Examples & Samples

Evaluate new and ongoing Total & Permanent (T&P) and Premium Waiver (PW) claims to determine MetLife’s liability
Make determinations on T&P payout claims up to $50,000 and Premium Waiver claims up to $500,000
Initiate investigations through both company and external contacts (i.e., employees, employers and physicians) to obtain medical and vocational evidence required for claim decision
Evaluate claims to identify situations requiring referral to Senior Examiner
Respond to written and/or telephone inquiries from policyholders, employers and physicians to resolve claim issues swiftly and thoroughly
Handle all stop, credit and reissue payment on returned and outstanding checks
Proactively interact with internal and external customers
Interact with LTD DCAS on companion PW and Disability cases
Handle Special Handle customers, such as Performance Guarantees, to ensure claims are completed in accordance with the specified customer requirement and agreement provisions
Perform post mortem reviews
Perform other related duties as assigned or required
2-3 years of insurance claims experience

141

Claims Examiner Resume Examples & Samples

Handling assigned claims across multiple jurisdictions, as well as setting the case strategy for these claims in partnership with Regional Practice Leaders and Claims management
Partnering with internal and external counsel in setting and pursuing effective and cost-efficient litigation strategies for claims in litigation
Coordinating and managing communication with internal and external stakeholders (e.g., Underwriting, brokers, reinsurers, external vendors, etc.) to ensure the highest level of customer service. Participation in new account and renewal meetings may be required
Consulting with Regional Practice Leaders and Claims management on Large Losses and ensuring all steps are taken to achieve the best outcome
Producing internal reporting and ensuring that reserves are set according to best practices guidelines
Identifying, monitoring and reporting on emerging liability and coverage trends
Broad surplus claims experience: minimum of 7 years of experience managing claims. Experience in the handling and management of general liability, with a focus on premises, auto and excess liability claims
Strong communication: Excellent verbal and written communication, presentation and negotiation skills. Able to communicate and negotiate effectively with internal and external stakeholders at various levels of sophistication
Collaborative approach: Develop productive working relationships with insured, brokers, claim handlers,
Underwriters and legal counsel. Seek input from others as needed to achieve the best result possible. Capable of working and collaborating with a virtual team
Strong ethics: Handle responsibilities with integrity and the highest standards of professionalism
Passion for results: Approach tasks proactively and anticipate needs. Think quickly and prioritize multiple work streams without sacrificing quality. Act with a sense of urgency
Intellectual curiosity: Willing to ask questions and explore new ideas. Eager to learn and focused on continuously improving technical skills
Ability to travel approximately 10%, typically for short duration trips
Possession of state adjuster licenses is preferred. Insurance designation(s) (CPCU, AIC, ARM) preferred

142

Complex Claims Examiner Resume Examples & Samples

Managing key claims handling enquiry; coverage determination, quantum analysis and legal liability assessment, where appropriate within authority limits and providing a consistently strong standard of customer service
Ensuring effective vendor and litigation management on Complex claims within a personal allocation
Broadening internal / external stakeholder communication where required
Contributing to maintenance of best practice procedures for Casualty intermediate to high value Complex claims, consistent with global best practice
Demonstrating a high standard of technical claims competence. Demonstrate a strong standard of competence in handling intermediate to advanced complex claims in Line of Business

143

Claims Examiner Resume Examples & Samples

Familiar with CMS and Department of Managed Health Care mandates
Ability to type 35 WPM, use a ten-key adding machine, perform data entry and make mathematical calculations
Spanish Bilingual

144

Claims Examiner Resume Examples & Samples

Processes/adjudicates medical claims according to regulatory processing guidelines and contractual agreements
Verifies patient account, eligibility, benefits and authorizations
High School Diploma or General Education (GED)
2-5 years medical claims examining experience; Experience in processing different types of claims; Minimum typing speed of 45 WPM and use of Ten-Key by touch
Working knowledge of ICD9-CM, HCPCS level II and III, CPT, and revenue Codes, DRG and APC coding
Working knowledge of different payment methodologies such as Medi-Cal, RBRVS, DRG and other Medicare reimbursements
Knowledge of different claims regulatory requirements such as California Code of Regulations, Title 28 Section 1300.71 Claims Settlement Practices/AB1455, CMS standards as defined in Title 42 Code of Federal Regulations (CFR) section 422 and other Medi-Cal/Medicare Claims Processing guidelines
Ability to comprehend and interpret documents such as provider contracts, procedure manuals, various reports, division of financial responsibility matrix (DOFR)
Ability to effectively communicate with internal and external associates
Ability to deal with complex claim issues
Ability to work in a fast paced environment with minimal supervision
Ability to handle multiple projects and is able to prioritize workflow
Intermediate PC program user (MS Word and Excel)

145

Claims Examiner Trainee Resume Examples & Samples

Adjudicate all claims to completion or returns to provider or member for additional or missing information
Process claims accurately and timely in support of MTM or other performance measures
Handle all claim edits appropriately including possible duplicates, eligibility status, corrected bills, manual pricing when appropriate, provider screen messages, authorizations, pre-existing condition, big bill guidelines, etc
Administer benefits according to Benefit Summary and or Online Help (OLH) processing guidelines
If necessary, route problem claims to TTE, Supervisor, CARR, UM or Case Management, COB, Subrogation Unit, etc
Compile processed claims in a processed folder with processor number and date in the secure paid claims department file for verification, quality and records storage when appropriate
Ensure timely and accurate completion of daily/weekly reports
Stay up-to-date regarding online resources, such as Online Help, BlueAlert, Medical Policy, and all other electronic resource changes when applicable
Keep abreast of changing divisional guidelines and government regulations
Recognize cause of problem and effect of resolution
Perform miscellaneous projects as assigned
Work overtime as required
Claims processing and/or customer service experience preferred
Customer service experience inclusive of restaurant, retail and/or insurance experience is acceptable
If current employee with the company, must meet minimum performance expectations
Previous health care experience is preferred
Microsoft Office products knowledge desired
Effective oral communication and interpersonal skills
Good written communication skills
Sound decision-making and problem-solving skills
Must be able to key 6500 keystrokes per hour with less then 10% error rate (if applicable)
Must be able to pass required testing

146

Claims Examiner Resume Examples & Samples

Verify, correct and complete claims information by telephone, letter or personal contact
Conduct investigations and gather supporting documentation on claims
Approve to a specified amount or denies claims in accordance with established procedures
2-3 years of financial services or related experience required
Retirement industry experience considered a plus
Bachelor’s degree or related experience considered a plus
Knowledge of defined benefit, defined contribution, non-qualified or related products
Experience with Prudential systems or external recordkeeping systems preferred
Ability to effectively communicate with internal and external parties
Strong organizational skills; self-motivated; flexible; ability to partner across functions
Creative problem solving, analytical and negotiation skills
Self-motivated and flexible; able to multi-task and thrive in a production-oriented environment and to handle requests in a confidential and professional manner

147

Life & Annuity Claims Examiner Resume Examples & Samples

Checks claim applications for completeness and accuracy
Ability to adjudicate claims more complex in nature and with level of independence, including contestable claims and/or ABR/WP/DI claims
Consults policy file to verify the information the claimant reports in a claim
Interprets policy language to assure adherence to the legal document, consults the legal department when needed
Authorized appropriate payment, denies the claim, or refers the claim to a more senior examiner
May oversee the work of a less senior examiner as well as co-approve a claim
Supports the training of new hires
Comfortable working on multiple claims at the same time

148

Workers Compensation Claims Examiner Resume Examples & Samples

Investigate claims to determine an injured worker’s entitlement to Workers’ Compensation benefits
Administers indemnity and medical benefits for valid Workers’ Compensation claims
Establish reserves, using independent judgment and expertise and authorize payments within scope of authority
Utilize time management and organization skills in order to timely respond to time constraints
3 to 5 years handling workers' compensation claims

149

Complex Claims Examiner Resume Examples & Samples

Managing key claims handling enquiry; coverage determination, quantum analysis and legal liability assessment, where appropriate for high value complex claims
Ensuring effective vendor and litigation management on Complex claims within a personal allocation, including demonstrable savings
Reporting key claims messages to their Team Manager and to internal stakeholders
Broadening internal / external stakeholder communication where required, as (LOB) technical claims expert and thought leader
Delivering technical training to colleagues and external contacts as appropriate
Assisting in continuous improvement across the region through support for the Quality Assurance - - Regional Audit processes
Ensuring adherence to best practice procedures for (LOB) Complex claims, consistent with global best practice
Handling higher level of complexity claims Complex losses within authority limits
Effective communication and management of key advanced Complex claims and (LOB) portfolio messages to internal stakeholders and customers/clients
Good presentation skills and file knowledge
Ability to influence claims and non claims stakeholders to effectively direct claims strategy
Well developed/Advanced expertise and knowledge in (LOB) most technically complex claims topics

150

Claims Examiner Resume Examples & Samples

High School Diploma or equivalency required. Associate Degree preferred
Minimum One (1) year of prior claims processing experience REQUIRED
Knowledge of medical terminology preferred
Knowledge of medical billing/CPT and ICD 9 coding or related experience required
Healthcare or managed care experience preferred
Minimum 35 wpm typing preferred
Working knowledge of PC applications in a windows based environment
Working knowledge of EXP/Macess and Facets operating systems
Displays the ability to multi-task, prioritize work and manage time

151

Temporary Future Medical Claims Examiner Resume Examples & Samples

Excess reporting and request for reimbursement where applicable
Good human relation skills, including the ability to work in conjunction with other administrative, management, and supervisory employees
Knowledge of claims handling and settlement procedures in the California Workers’ Compensation system
Familiar with Microsoft applications such as Outlook and Microsoft Word

152

Future Medical Claims Examiner Resume Examples & Samples

Payment of benefits where applicable (Life pension, PD, medical bills and medical mileage reimbursement)
Diary compliance (new mail & CMR’s), verify, analyze and appropriately establish reserves based on lifetime exposure
Verbal and written communication with our injured workers and clients
Adhere to client protocols as well as York operating definitions
1 to 3 years of experience in claims handling operations
Public Entity experience a plus

153

Hms-claims Examiner, Cleveland Resume Examples & Samples

Adherence to all Health Management Solutions (HMS) policies and URAC standards
Process all Treatment Requests (C-9s) within 72 hours to provide the IW with the treatment medically necessary and appropriate for the Allowed Conditions
Effectively apply the MCO process including completion of appropriate medical management template, documentation of community resources, support systems, and psychosocial factors that may represent potential barriers to a successful RTW

154

Claims Examiner Resume Examples & Samples

Consistently ensure timely and accurate acceptance of claims through the review of claim history and edit or deferral reports including the simple manual computation of benefits, both in- and out-of-network, by entering data using available resource materials such as contracts, contract benefit files, etc. Refer questionable and non-routine claims to more experienced personnel
Recognize and report problems and potential errors in network, fee schedule, or other plan systems
Analyze the reasons for the edits of the claims data and take appropriate action needed to process claims, including directing claims to Medical Management for medical determinations
Recognize, investigate, and report immediately any abnormal or aberrant claim practices or system configuration issues to the Supervisor or Senior Claim Examiner for review
Recognize incorrectly processed claims in the member’s history, watching for cascade errors on all previously processed claims and creating and intake for appropriate personnel
Record and submit daily accurate data on the Individual Operating Report (IOR) for the Management Information and Control System (MICS)
Access online manuals, contracts, organized memos received through Outlook, and stay current on all other information related to benefit administration
Develop and employ inventory evaluation skills using good time management
Six (6) months previous claims-related work experience, including Data Entry, in the health care or health insurance industry
Medical terminology, Claim processing procedures helpful
MS Office Suite to include: Outlook, Word, Excel
Ten-key (100+ kspm)
Typing (45+ wpm)
Verbal and written communication
Math – Basic
Organizational
Understand and follow detailed workflows and instructions
Work independently or in a team environment
Work overtime as needed

155

Complex Claims Examiner Resume Examples & Samples

Contributing to maintenance of best practice procedures for (LOB) claims, consistent with global best practice
Effective communication of key claims and (LOB) portfolio messages to internal stakeholders
Experience in dealing in managing your own claims portfolio
Expsure to property, strata or landlord claims
Ability to interpret and apply the applicable policy wordings
Requires proficiency in Desk Management, phone ‘etiquette’, time management and dealing with difficult customers
Strong decision making skills

156

Complex Claims Examiner Resume Examples & Samples

Contributing to maintenance of best practice procedures for (PCG) Complex claims, consistent with global best practice
Private Client Group – House, Contents, Private Collections, Safeguard and Yacht
Graduate Diploma of General Insurance or equivalent is desired but not essential
Comprehensive experience in dealing with high net worth domestic insurance claims including house, contents, private collections, safeguard and yacht
Proven ability in the interpretation and application of domestic policy wordings
Experience with claim negotiations and strong interpersonal flexibility is a necessity
Demonstrated capability in the effective management of various stakeholders including loss adjusters, lawyers and other experts
Ability to develop and maintain highly effective relationships with all stakeholders, brokers and clients

157

Workers Compensation Claims Examiner Associate Resume Examples & Samples

Ability to prioritize multiple tasks and meet deadlines
Medical and legal terminology preferred
Integration with Medicare preferred
0 to 2 years

158

Associate Claims Examiner Resume Examples & Samples

Reading and analysing Technical Processing submissions
Processing Technical Processing, Threshold Technical Processing, Technical Accounting, Claims Transformation and Non Peer Review claims within authority level
Validating data and obtaining additional information to clarify documentation and where necessary correct inaccuracies
Identifying questionable and / or potentially non-compliant data and initiating action to correct or resolve independently where a standard course of action is set out
Processing Non-Cash / Direct Reports / Beazley / Direct Settlements
Processing and handling specific accounts
Processing files ensuring high quality statistics are achieved (over 99% of files are processed correctly)
Communicating with the Team Leader, Claims Adjusters, Brokers, placing Brokers, Managing Agents and (re)insured’s
Covering the Technical Processing Urgent Paper Queues and Appointments
Positively engaging in new initiatives to support the Team Leader achieve Processing and Quality SLA’s
Assisting in the development of new / revised procedures and reference materials
Developing and maintaining current technical knowledge sufficient to efficiently and effectively complete work
Working with and seeking the assistance of more experienced employees to deal with the handling of complex matters
Managing time effectively working within established guidelines applying standard technical checks without supervision
Dealing with and Resolving problems with a high degree of independent judgement
Demonstrating and encouraging commitment to team objectives
Recognised as a go-to person, offering assistance to less experienced team members
A good understanding of the London Market practices and procedures
A solid understanding of Technical processing processes and procedures
A high degree of independent judgement for decision making and problem solving
Ability to listen to and resolve customer issues whilst preserving relationships (by being effective, efficient, tactful and courteous)
Good communication skills with the ability to relay non-routine information clearly and concisely in both written and verbal communication
Conducts themselves by example adapting positively to support change initiatives; promoting professional image of self, the team and XCS
Maintaining a positive attitude assisting in raising and maintaining team spirit and moral

159

Healthcare Claims Examiner Supervisor Resume Examples & Samples

2-4 years of Healthcare Claims expertise
Supervisory or leadership experience
Strong verbal communication
Preference for knowledge on MMIS Fiscal Agent Operations
Preference for knowledge on business processes of the NC DHHS and or NC Health Choice

160

Life & Annuity Claims Examiner Resume Examples & Samples

Process claims under supervision in an accurate and timely manner
Communicates claims action/processing with claimant, client, and agent
Enters accurate claim information into the system to assure correct claim payment, correct benefits and documents file thoroughly and clearly
Supports other claims examiners and claims manager with large or more complex claims as assigned
Ability to troubleshoot and resolve basic problems using standard work processes
Properly documents files and adheres to the state insurance regulations to minimize potential litigation
Reviews complex and/or contestable claims with the oversight of a more senior examiner or manager

161

Claims Examiner Resume Examples & Samples

Bachelor's degree or minimum of 1-2 years equivalent work experience
Experience in a transaction processing and service oriented environment that includes quality and productivity standards, and meeting service level agreements
Ability to communicate both verbally and in writing
Strong mathematical and analytical skills
Able to reconcile numbers
Flexible with the ability to multitask and manage conflicting priorities
Proficient with MS Office Word and Excel
Able to work every 4-5 weeks until 4:30 PM EST to answer the NIGPP phone line
Able to work overtime as required
Able to train initially in Scranton, PA, and periodically, thereafter

162

Associate Health Claims Examiner Resume Examples & Samples

This position is located in Appleton, WI. Relocation assistance may be available.**
Determine extent of liability on routine claims and make final claim decisions within specified dollar limits. Contribute to accurate fraud detection and reporting by referring suspected fraud to appropriate staff for review according to established procedures
Analyze claim transactions and process payments utilizing various work flow, administrative, and LOB (Line of Business) systems, accurately and cost effectively according to contract provisions and in compliance with internal service and state and federal regulatory standards
Ensure high level of customer satisfaction by partnering with members, financial associates, doctors, providers, attorneys, police, vendors and other internal and external customers regarding claims, settlements and interpretation of policy provisions, which may include highly confidential information or complaints, often educating the recipient on products/benefits and regulatory requirements
Handle sensitive written and verbal communications. May be called upon to influence behavior via these communications
Assist in the development and implementation of business processes, standard operating procedures, documentation and other support materials required for unit operation
This position has the authority to make final claim decisions
Use sound decision-making to determine extent of claim liability to avoid significant or long-term monetary impacts to claimants, beneficiaries, members and the organization
In-depth knowledge of medical terminology and human anatomy. Ability to comprehend/interpret a variety of medical records and legal documents to extract and combine relevant pieces of information to formulate a decision
Accurate claim processing requires decisions based on identifying specific product provisions and rules, various system capabilities and knowledge of regulatory and product/benefit guidelines in order to maintain claimant and beneficiary satisfaction as well as avoid non-compliance with regulatory guidelines
High school required. College degree preferred
Less than two years related experience preferred. Healthcare, Medicare, health insurance or other related industry background preferred
Professional credentials preferred in the healthcare arena
Basic knowledge of claim administration and operations as well as pertinent laws and regulations
Serve as an advocate for Thrivent and representing the organization, processes and employees in a positive light to help grow, engage and retain membership
Demonstrates excellent interpersonal skills as well as verbal and written communications skills
Demonstrates resilience in the face of ambiguity, shifting priorities and rapid change with minimum supervision
Beginner to Intermediate knowledge and use of Microsoft Suite, primarily in Word, Excel, PowerPoint, and Outlook is desired. Keying data entry efficiently, speeds, and accurately with proficiency in typing/keyboard is required
Ability to quickly learn complex program and product knowledge, work on a PC, accessing and navigating multiple software applications in a Windows environment
Accurately answer and address customer questions and concerns using verbal communication to a deliver a high level of customer experience
Utilize resources and stay up-to-date with current/new information, e.g., access Livelink, read the Weekly Summary, attend meetings, etc…
Bring forward continuous improvement ideas, trends, or issues identified to managers in a timely manner, promoting solutions as appropriate

163

Claims Examiner Resume Examples & Samples

Meet and/ or exceed claims processing production requirements
Maintain statistical accuracy of 97%, and financial accuracy of 98%
Correct DoD error report as needed
Provide excellent customer service to internal and external customers
Collaborate with and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate completion of tasks/goals
Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
Preferred: Claims processing experience - Medicare Advantage

164

Coordination of Benefits Claims Examiner Resume Examples & Samples

Basic mathematics aptitude
Review forms, electronic claims and related documents for completeness
Correspond (by letter, telephone and in person) with members, employers, providers of service and other HealthPartners personnel regarding missing data and coverage determinations
Review and determine primacy rules according to NAIC guidelines
Identify and interpret Explanation of Benefits received from multiple carriers
Coordinate benefits with multiple financially-responsible parties according to NAIC guidelines
Adjudicate Primary Care claims for payment, denial, or disallowance in accordance with plan provisions, policies and procedures
Perform system overrides to manually calculate the amount of benefit for claims when plan benefits and provider arrangements allow for multiple options and the system is unable to automate the calculation
Resolve system error edits
Make judgments regarding covered services through a review of patient history and the appropriate application of plan policies and procedures
Meet established production and quality, pend management and aged-document management standards

165

Senior Associate Claims Examiner Resume Examples & Samples

Fiduciary Account Handling/Credit Control - The Fiduciary Accounts Advanced Technician has responsibility for credit control processes and other duties directly relating to Aon clients, whilst ensuring that functions are fulfilled to the agreed standards and timescales. Duties include
Ability to work independently with little technical supervision
Experience in processing, researching, validating and handling more complex work items
Experience of having to make independent judgment calls on actions required in problem-solving non-routine cases
Ability to work within established guidelines applying technical checks for both work completed by themselves and appropriate offshore team as they relate to activities surrounding payment or collection of a transaction
Relevant Fiduciary Accounting experience in an outcome focused environment with a proven track record in delivering results
Fiduciary Accounting experience/knowledge to a level that allows assisting less experienced employees in the handling of complex matters
Experience in the development and documentation of new/revised process or control procedures
Experience of working within a regulatory framework with strong knowledge of Fiduciary controls and processes
Ability to; identify questionable and/or potentially non-compliant data/matters and to take prompt action to correct or resolve independently where a standard course of action is clearly prescribed. Escalate as appropriate where the action requires
Ability to write clear and concise summary of telephone conversations and required actions
Strong personality and pleasant manner
High standard of communication, both written and verbal
Good IT Skills, specifically Microsoft Excel
Demonstrate personal commitment
Good Attention to detail
Well organised, able to plan and prioritise
Adaptable and flexible individuals who are not hindered by preconceived ideas about the role or work
A minimum of 3 GCSE's at Grade C or above including Mathematics and English
A sound knowledge of Word, Excel and Outlook
A working knowledge of Either Atlas, PURE or Brokasure an advantage

166

Claims Examiner Workers Compensation WA Resume Examples & Samples

Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner
Ensures claim files are properly documented and claims coding is correct
Travels as required
PC literate, including Microsoft Office products

167

Senior Claims Examiner Resume Examples & Samples

Responsible for benefit payments and state required notices in compliance with the Workers’ Compensation regulations, as concerns disability benefits, rehab issues, objections, etc
Negotiates settlements with injured workers and applicant attorneys within assigned authority and prepares settlement documents
Responsible for completion of Stipulations or C&R’s and obtaining employee signatures and approval of the Workers’ Compensation Appeals Board. Appearances at the Workers’ Comp Board as needed
Proactively directs and manages defense attorneys on litigated files
Supervision and training of claims compliance assistant and clerical support
Diaries filed timely and appropriately
Reviews and documents all mail, in a timely manner
Conducts file reviews with plant management, as required
Administrators Certificate from Office of Self-Insurance Plans
Must possess a current Experienced Claims Adjuster Designation, as defined in California Code of Regulations, Title 10, Chapter 5, Subchapter 3, Section 2592.01(f)
Requires solid knowledge of California Workers’ Compensation Laws, policies and procedures
Proficiency in determining case value
Requires understanding of medical and legal terminology
Ability to work in a paperless environment

168

Workers Compensation Claims Examiner Resume Examples & Samples

Responsible for the investigation, analysis and evaluation of all assigned cases through telephone or personal interviews with the injured employee, employer and all other pertinent parties. Gathers all available information and transcribes it into the claim file with sufficient detail. Continues to gather all pertinent data as long as claim file remains active
Evaluates data for compensability and recommends case reserve based on approved reserving procedures. Case Analyst 2 is able to react to events as they unfold and adjust reserves accordingly. Properly completes Claim Summary Reports in a timely manner
Recommends assuming payments or denial of claim. Must have good working knowledge of NY Medical Treatment Guidelines and be able to adjust claims within the rules set forth by the workers compensation board
Provides data to Case Management Team members and assists in the development of a treatment and return to work plan. Responsible for the implementation of the plan working collectively with the Patient Advocate. Regularly telephones injured employees to assist in their efforts to return to work and facilitate an equitable resolve to the claim
Responsible for compliance with all regulations from the Workers’ Compensation Board including timely EDI and compliance reporting requirements and resolution of any EDI and/or compliance issues
Responsible for each case’s compliance with established service standards and procedures. Excellent usage of organization best practices
Organizes workload so that all cases receive the proper claims handling and are promptly brought to a conclusion. Effective usage of work management system and office work flow
Oversee workflow of claims unit and assist in the administrative duties
Will assist the program development and refinement as from time to time becomes necessary
Skills/knowledge - Excellent communication and negotiation skills required. Good analytical ability combined with common sense and the ability to empathize with those in traumatic situations. Maintain the highest of reputations for the fair handling of claims. Develop strong, outgoing business relationships with employers and employees. Ability to work as a member of a team and to work with team until task is completed
Does the employee need to be bondable? Yes
Physical effort and dexterity -Occasionally the Case Analyst 2 will be required to lift and carry up to 15 pounds. Some stooping and kneeling will be necessary. Reaching and handling files, as well as keyboard and telephone operation, will be frequent activities
Visual acuity hearing and speaking -Speaking and hearing in ordinary conversation situations will occur frequently. Visual abilities need to include comfort with the PC screen and ability to see and read reports
Environment and scheduling -85% of the job is spent sitting down, either on the telephone or at a PC station. 10% is walking and the additional 5% is spent standing. 90% of this job will be performed inside and 10% outside. 35-hour workweek. Travel required
Employee must already hold, or secure New York State Adjuster license within 90 days of appointment

169

Claims Examiner Resume Examples & Samples

Previous health, dental, or vision insurance experience
Previous claims processing experience
Microsoft Windows experience

170

Contract Claims Examiner Resume Examples & Samples

Reporting Responsibilities
Meets production standards of 100-150 Hospital claims per day and 200-250 IPA claims as established by claims management
Assists in other IPA's when needed
Submits automation requests through SharePoint
Process Customer Care Inquiries
Reviews pre-check run reports and/or Reviews and releases pended claims from the PEND buckets (ELIG, AUDIT, MGR, UM, CLER, etc.)
Assists with training new hires
Performs other tasks as assigned by supervisor/manager
Attends training meetings and ask questions
Provides auditor with training suggestions/example
Submits training survey after each training
Adhere to Claims Department policies and procedures. Keeps updated materials and resources provided for accurate and expedient adjudication
Ensure that the Examiner's Checklist is verified and done

171

No-fault Claims Examiner Trainee Resume Examples & Samples

Learn to handle most aspects of auto claims
Develop a basic understanding of the content of policies written by the company
Develop a basic understanding of the insurance industry and the organizational relationships of the company
Develop a basic understanding of the functions of other departments, such as Policy Ops and Marketing
Learn how to determine subrogation or fraud potential and how to handle
Develop a basic understanding of systems and technology used within the company
Identify customer needs and works to meet those needs using appropriate customer service skills
Perform other projects and assignments as directed
Successfully completes Claim Representative trainee program
Obtaining/Maintaining appropriate licensing or educational requirements
Learn customer service and time management skills through training classes as part of the trainee program
Learn to recognize and identify all body parts of a vehicle and/or understanding other potential property damage
Develop understanding of claim policies & procedures; refers questions to supervisor
Learn to interpret and apply written coverage accurately to establish claim and determine an action plan
Develop ability to handle repair/replace decisions
Develop labor judgment skills and learn to complete simple estimates accurately
Learn to handle some comprehensive losses (theft, fire, and vandalism) with direction from more experienced personnel
Develop ability to handle injury claims and acquire a basic understanding of how to review, evaluate, and negotiate simple or basic injury claims
High degree of initiative, mature judgment, and discretion. Ability to resolve conflicts and empathize with customers is critical
Negotiation skills are important for resolving claims
Gains a general understanding of insurance law as it relates to claims
Demonstrate a thorough understanding of the NGI Insurance brand and ability to exhibit the behaviors

172

Workers Compensation Claims Examiner Resume Examples & Samples

Administers and manages basic to moderately complex active claims within workers compensation policies and guidelines
Certifies or denies claims based on investigations by examiners, other departments, medical documentation, application of state statutes and rules, or third party recommendations
Develops and manages action plans to facilitate resolution of claims; coordinates return-to-work efforts
Ensures claim files are properly documented and correctly coded
Determines if treatment is reasonable for the allowed condition. Assists in identifying or scheduling claims for independent medical or functional capacity exams
Reviews reserves, sets reserves, and determines if reserves are appropriate for claim. Ensures claim reporting to excess carrier
Reviews, evaluates and negotiates settlement of claims up to designated authority level
Processes claims including calculation and payment of benefits due, as well as approval and timely payment of claim and adjustments. Files necessary documentation with appropriate state agency
Identifies subrogation opportunities
Prepares strategy for the defense of denied claims and determines exposure potential for the settlement of claims. Works with legal counsel and assists with discovery
Requests hearings and may attend trials and hearings as a representative of the company. Drafts and reviews motions or appeals as needed
Participates in claim reviews
One to three years previous experience in Workers Compensation preferred
Certification from a state recognized claims management program preferred
Strong PC and Microsoft Office skills with proficiency in Word and Excel preferred
Ability to learn and utilize claims management system required
Strong oral and written communication skills required
Ability to travel on a limited basis required

173

Complex Claims Examiner Resume Examples & Samples

Ensuring effective vendor and litigation management on Complex Claims within a personal allocation
Broader internal / external stakeholder communication where required as Auto Technical Claims Expert
Strive for continuous improvement on claim file handling with feedback and support through the Quality Assurance Review processes
Assist in continuous improvement across the region through support for the Quality Assurance / Regional Audit processes
Ensure adherence to best practice procedures for Auto Complex claims, consistent with global best practice
Delivery of technical training to colleagues and external contacts as appropriate
Handle higher level of complexity claims, complex losses within authority limits
Any other projects/tasks which may be assigned to you from time to time
Effective communication of key advanced Complex Claims and Auto Claims portfolio messages to internal stakeholders
Attain objectives for assigned projects
Benchmarks for claims processing and file closure

174

GL Senior Claims Examiner Resume Examples & Samples

Assess insurance coverage based on the policy and claims report to determine if claim can be accepted as being within coverage
Conduct a thorough analysis of liability and damages; continually assess exposure and evaluate for accurate reserves
Insurance coursework (e.g. IIA, CPCU, SCLA and AEI) is beneficial

175

Claims Examiner Resume Examples & Samples

Review, process and conclude moderate severity claims that may be limited in exposure but occasionally complex in nature
Verifies coverages and policy conditions
Documents all correspondence, reports, discussions and decisions
Ability to communicate effectively and clearly, both orally and in writing
Ability to effectively operate computer equipment and applications

176

Absence Claims Examiner Resume Examples & Samples

Provides a diverse range of information and performs a diverse range of tasks/transactions related to common programs and services
Prioritizes, reviews and processes absence claims with sound and impartial judgments, using appropriate duration guidelines
Facilitates effective transition of claims, utilizing established review procedures and resources
Applies expanded knowledge obtained for the role to effectively communicate with internal/external stakeholders on claims to obtain needed information while maintaining a professional demeanor in all interactions
Handles requests from email, answers questions from stakeholders, resolves system issues, and corrections
Recognizes increasingly more complex service issues/concerns for assigned area(s) of responsibility, explains effect on the customer's service experience, and suggests process improvements

177

Adjustment Claims Examiner Resume Examples & Samples

Review adjustment from all areas within HealthPartners and interpret instructions
Respond to phone inquiries and member correspondence inquiries regarding claims adjustments
Compile statistical information regarding reviewed claims and report results to appropriate Supervisor
Meet established production and quality standards
Keep abreast of current information and changes impacting claims processing
Organize relevant information for daily reference
Perform other duties as assigned by HP management

178

Claims Examiner Resume Examples & Samples

20% General Claim Events: Support the business by processing general claim events, including but not limited to
70% Phone Calls: Support the achievement of the team through outbound and inbound phone calls regarding claim events
1 year experience in customer service (preferably in a call center environment) and computer skills using multiple Windows applications
Excellent verbal and written communication skills, as well as be punctual and reliable
You must be motivated to provide exceptional customer service
Customers must be able to understand associate's speech over the phone
Candidates must be willing and able to work Monday - Friday, 9:00am to 6:00pm and be flexible to work overtime or weekends if necessary
1 year experience in insurance (life or health)
1 year Customer Service Experience in office environment
Bilingual English/Spanish a plus

179

Senior Claims Examiner Resume Examples & Samples

Gathers, organizes, and documents information on all incidents, including guest injuries and property damage for 21 parks in 10 states
Initiates contact with guests, gathers witness statements and other evidence, reviews medical records
Investigates, prepares settlement evaluations and recommendations, and negotiates/settles general liability bodily injury claims with coordination and approval from the General Counsel and Manager- Risk & Litigation
Coordinates pre-litigation investigations with the parks and defense firms
Identifies subrogation potential for property loss claims and prepares/submits proper documentation
Participates in general liability litigation strategy meetings/discussions
Some travel may be required (mediations, etc.)
Reports directly to the Manager – Risk & Litigation, with ultimate reporting responsibility to the General Counsel, as part of the Legal Team. Works closely with both, in addition to Legal staff, safety, park personnel, insurance carriers and brokers
Six years of claims adjusting experience
California Property & Casualty Adjuster license preferred
Multistate legal and insurance regulations knowledge preferred
Must be able to comfortably and confidently manage a substantial amount of work flowing from multiple locations and personnel across the country
Excellent communications abilities, organizational, analytical and problem-solving skills

180

Workers Compensation Claims Examiner Resume Examples & Samples

Knowledge of utilization review procedures, permanent disability and life pension is mandatory
3 years' experience handling California Workers' Compensation Claims
County of Los Angeles experience preferred

181

Claims Examiner Resume Examples & Samples

Review and provide resolution for claims rejected by the auto-adjudication process in accordance with the departmental accuracy and responsiveness standards using the claims/image system and various sub-systems
Recognize procedure codes, tooth numbers, etc. and understand how they interrelate to ensure claims for all products were processed appropriately. (Functions will include claims processes for all products - dental, vision and hearing products)
Resolve inquiries and problems and arrive at a quick, accurate and satisfactory resolution. Manually process claim re-submissions
Knowledge of various contracts and marketing arrangements, including PPO contracts and service guarantees. Interpretation of coordination of benefits and other policy provisions, company practices and transition guidelines
Apply policy provisions and knowledge of company philosophy to ensure compliance with the contract, legal requirements and guidelines established by various states’ regulations
Provide second review of claims
Work the front desk, either as primary, back-up, or as part of a rotation with other associates
Back-up the Group Support Specialist in San Antonio as directed by management
Ability to work periods of overtime as required based upon business need
Provide support to the contact center by answering customers’ inquiries via phone, and have an understanding of the phone system
Experience in a dental related field or claim processing environment helpful
Ability to work independently and handle multiple duties
Must possess good grammar in speaking and writing; should have good verbal skills in formal and informal business settings, and be able to write clearly
Focused on continuing educational development opportunities
Proficient use of personal computer system and keyboarding skills
Ability to maintain current knowledge of claims/image system, all procedure codes, and customer service standards; as well as the diverse components in the various products, marketing arrangements and panel leasing arrangements
Ability to appropriately apply the Coordination of Benefits provision with respect to other dental carriers, pre-paid carriers, medical insurers, individual coverage and other entities in which duplication of benefits may be provided
Ability to effectively utilize multiple mainframe business systems
Ability to quickly adapt to new procedures and job functions derived from changes in laws and business relationships
Ability & willingness to work positively in a Team environment

182

Claims Examiner Resume Examples & Samples

HS Diploma or GED required
Position will require pre-employment screening such as interview, references check, and drug/background screening prior to start date
Computer skills to include MS Office Suite
Accurate Typing & 10-key Skills
Requires 2+ years general office experience – experience in medical/healthcare related office preferred
Experience in claims and/or healthcare/insurance customer service preferred
Excellent verbal & written communication
Attention to detail & ability to follow workflows/directions

183

Claims Examiner Resume Examples & Samples

Maintain employee/insured confidentiality
Participate in training programs as available/requested
Process MCNet/Batch Edit errors in accordance with designated standards
Process standard to moderate claims, including COB, in accordance with company policies and procedures in a timely manner while meeting or exceeding production and quality standards
Work overtime as required per business need

184

Employer Life Claims Examiner Resume Examples & Samples

Reviews, investigates and manages caseload assigned to meet productivity, quality, and time service standards. Maintain detailed knowledge of claims practices, policies and procedures
Works with mentor/leader to make payment determination applying appropriate contractual provisions and payment calculations using claims system, as well as applicable state liens checks, to manage and pay claims while meeting all service, timeframe and production standards. Provide secondary claims review and payment approval support for Claims team
Ensure compliance with all state and federal regulations and internal department procedures and goals; legal guidelines case management resources; and claim procedures, concepts, principles, and protocols to risk manage life claims
Responds to various written and telephone inquiries including eligibility, approval/denial determinations, status and continuation or closure of benefits
Provides high-touch service through Personalized Case Management to our beneficiaries
Identifies and appropriately handles suspicious claims, partnering with senior team members for guidance and assistance
Intermediate level knowledge of life insurance, contracts, riders, benefits and agreements; in-depth understanding of applicable state/federal regulations
Effective critical thinking, problem solving, and decision making skills
Effective verbal and written communication skills to exchange complex information from various sources
Customer focus with demonstrated ability to empathize with beneficiaries
Tact, composure and professionalism
Time management and organizational skills
Knowledge, skills and other capabilities normally acquired through Bachelor’s degree (or equivalent relevant experience) and at least one or more years of life claims experience

185

Complex Claims Examiner Resume Examples & Samples

Process monthly claims bordereaux and/or imprest reports including FNOL, reserving, payment processing and closing of files
Takes ownership and follows through on agreed commitments and will take the initiative to overcome problems and implement solutions swiftly
Timely, accurate and customer focused claims administration resolution
Property – S.M.E, Consumer, Strata, Real estate/office, Leisure (hotels, resorts, fitness etc)
Auto
Marine - Pleasurecraft
Good communication skills, both written & verbal
Ability to contribute effectively within a team environment
Ability to work with claims stakeholders to effectively direct claims strategy
Specialist knowledge in (LOB) technical claims topics
Knowledge of legal / regulatory and litigation / procedural requirements for their line of business

186

General Liability Senior Claims Examiner Resume Examples & Samples

Prepare Large Loss Reports and maintain ongoing claim updates
2+ years’ experience in job-related functions
Maintain valid adjusters’ license(s) in states assigned or an ability to obtain same
Ability to manage relationships in a fast paced environment, while demonstrating persistence along with problem solving and decision making skills to work with customers through a variety of challenging situations

187

Claims Examiner Resume Examples & Samples

Collects and inputs required Insurance Bureau of Canada coding
Manages claim recoveries, including but not limited to: subrogation
Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices application procedures as applicable to line-of-business

188

Veterans Claims Examiner Resume Examples & Samples

A Bachelor's degree from an accredited college or university and experience in counseling, interviewing and handling veterans' affairs. Experience as described above can substitute on a year-for-year basis for the required college education. E-7 or above rank may substitute for the required education
Effective communicator and Team Player
Excellent interpersonal skills and customer service skills
Strong organization skills and ability to multi-task
Proficiency in Microsoft Office Suite: Word, Excel, and Outlook
Proficiency in web-based applications and specialized internet research
Successful completion of a Level 2 Background Screening

189

Associate Claims Examiner Resume Examples & Samples

Overview of Admin systems (Cyber Life)
Product training / Life Insurance Industry
Process Training
Challenging role in which every day will be different
Defined Career path
Department is experience tremendous growth

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