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Claim Specialist Resume Samples
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6-10 years of experience
Resolved customer complaints arising from faulty flooring products and installation issues.
- Hired and supervised all flooring installation crews.
- Inspected job sites and documented resolution activity.
- Filed claims with manufacturers and tracked manufacturer reimbursements.
- Completed approximately 20 assignments per month from homeowner insurance carriers.
- Performed site inspections to determine the extent of property damage due to water, fire or vandalism.
- Completed repair / replacement estimates using the Xactamate program and submitted estimates to the insurance companies.
- Assisted customers with flooring selections, and arranged repairs / replacements according to the carrier's guidelines.
0-5 years of experience
Oversee claims processing, including law suits, arbitration, and multiple vehicle accidents. Asses, develop, and review cases related to vehicle theft and arson. Command investigations and appropriate action involving arbitration and lienholder interest cases. Collaborate with internal clients to resolve claims with due diligence, effectively establishing and maintaining continually positive working relationships.
- Achieved Top Third in production of Complex PD Employees.
- Outstanding customer service, focused on follow through and accountability.
- Recognized and identified potential fraudulent claims.
- Resolved coverage questions.
0-5 years of experience
- Successfully resolved all types of property claims within an assigned territory.
- Performed all 2-story and steep roof inspections for the local claims office with 6 adjusters.
- Assisted Catastrophe Services Claim Teams where and when needed, providing quick and accurate resolution to large numbers of claims in varying geographic locations.
- Utilized as a dispute resolution resource resolving differences between policy holders, contractors and insurance company.
0-5 years of experience
Responsible for identifying potential areas of risk concern regarding claims and escalated them for additional verification or investigation.
- Researched claims and identified and reported deficiencies, inconsistencies, and/or misrepresentations as required.
- Provided quality control FNMA and FHLMC claims selected by chase Pipeline Prioritization System and submitted findings to management.
- Reviewed loan files to ensure all compliances were met regarding investor guidelines, credit quality, and data integrity for investors/clients such as FNMA and FHLMC.
0-5 years of experience
- Identified, investigated, evaluated, obtained and utilized critical information required to accurately and objectively adjudicate complex Long Term Care claims
- Made claim eligibility determinations based on the claimant's contract and other information provided at time of claim, as well as determined the need for additional information to properly determine risk
- Effectively managed and prioritized a work queue and multiple job responsibilities in a fast-paced environment, frequently with aggressive deadlines
- Recognized and worked within a structured environment with clearly defined SOP's to ensure consistency of claims practices and resolutions
10+ years of experience
Initiate claim negotiations with insureds, claimants, and attorneys. Control adjustment expenses through settlement of first party claims. Apply knowledge of building industry and repair techniques. Provide factual, legal and medical analysis. Comply with governmental/company regulations.
- Received "National Spirit of State Farm Award" for outstanding leadership and "Remarkable Service Award" for excellence in customer service.
- Minimized delays by demonstrating scheduling flexibility.
- Utilized proven customer service skills to provide a simple, caring, and personalized experience to both internal and external customers.
- Added value with a willingness to assist team members with issues requiring immediate attention.
- Handled complex claims and acted as a subject-matter expert.
- Positively engaged with team members and management to share perspective and support of company goals.
- Established familiarity with many contacts in the industry which enabled efficiency in addressing unique and difficult challenges.
- Built and leveraged relationships to assist in diligent investigations.
0-5 years of experience
- Promoted to operations disability leave administrator.
- Efficiently utilized Microsoft excel by importing text file data and create data model, modify pivot table fields, import data from spreadsheets and create customized tables, format spreadsheets, V-look up, create relationships between imported data.
- Daily demonstrate the ability to provide detailed examination of data, medical documents, claim history from beginning to end as a basis for leading clinical round table discussion.
- Demonstrated effective verbal and written communication skills interacting with administrators, claimants and providers.
- Disability claim management certified.
0-5 years of experience
- Processed claims quickly and accurately; Investigated claim issues
- Made recommendations to management for process improvements
- Researched issues and obtained proper supporting documentation in a timely manner as requested by the investor
- Managed application of claim funds received
- Validated all funds have been received prior to claim being closed
- Monitored claim process reports to ensure all required responses are filed in time
years of experience
Processing/reprocessing claims in a timely matter accurately and effective for doctors and hospitals.
- Following processing procedures set forth in mentor to provide quality customer service.
- Researching medical documents for dispute payments, sending medical notes to various medical physicians for approvals/denials on underpayments, overpayment or denials.
- Provide payment to claims accordingly to the member's benefit plan guidelines along with a letter to the provider, notifying them about their dispute.
0-5 years of experience
- Wrote memos and correspondence for claim handling activities
- Recommended and negotiated settlement offers
- Investigated an analyzed client complaints to identify and resolve issues
- Conducted claim and estimate re-inspections
- Communicated with injured parties and legal representatives for claim handling
- Obtained all necessary information to complete proper evaluation
- Investigated Agent Draft Authority claims, determined losses and reported findings
- Mentored new claim staff members
- Reviewed data to verify validity of claims
0-5 years of experience
- Manage an inventory of worker’s compensation claims and evaluate compensability decisions by conducting a thorough investigation.
- Update files and provide comprehensive reports to clients
- Knowledgeable of worker’s compensation state laws of IL, IA, KS, and MO
- Establish relationships between the Company, Legal Counsel, and the Client
- Evaluate and establish loss cost estimates by using company resources to determine best probable outcomes of claims
- Evaluate and resolve claims by pricing and negotiating for a settlement resolution
0-5 years of experience
- Investigate claims and obtain relevant facts to determine coverage, loss and liability.
- Oversee legal and medical aspects of claims to ensure treatment is reasonable, related and necessary to the auto accident.
- Maintain current on all licensing and training requirements for claims handling including Medicare and Workers Compensation fee schedules
- Manage a claims inventory of over 150 files from inception through resolution.
0-5 years of experience
- Excellent written and verbal communication skills
- Strong experience in investigation of complex and unusual claims
- Analyze and authorized payments for covered claims.
- Keeping abreast of company news and policies to ensure claims are assessed along the correct lines.
- Arranging for delivery of parts or replacement items if a claim requires it
10+ years of experience
- Interpret policies and analyze details gathered to determine proper claim objectives
- Prioritize contact of various parties associated with the claim, ensuring efficiency
- Gather details on status and treatment needed of those injured in an accident
- Evaluate and settle unrepresented bodily injury claims
- Determine liability per state guidelines
- Negotiate with customers and other insurance carriers
- Promote exemplary customer service by delivering consistent claim service quality
6-10 years of experience
- Register claims, update status notes, establish target dates, and communicate effectively with attorneys, medical staff, insured's and claimants and uphold high standards of business practices.
- Collect facts of loss and conduct initial analysis.
- Research, resolve and settle claims within approved limits, and recognize potential NICB indicators.
- Analyze medical records, legal documentation to maintain accurate records to determine settlements.
- Obtain information and maintain records of accidents or personal property losses for policyholders and claimants through telephone and written reports.
- Responsible for acquiring jurisdictional knowledge, for proper claim handling in multiple states.
- Research and communicate information regarding insured's claim status, benefits, with confidentiality.
0-5 years of experience
- Researching and Responding to complex telephone, electronic and written inquires
- Resolving customer complaints
- Providing excellent service to customers regarding eligibility, benefits and claims
- Ability to locate mistakes on claim forms
0-5 years of experience
- Experience billing for Family Medicine, Orthopedics, and Chiropractic and acted as a liaison between the doctors and the insurance companies.
- Demonstrated the ability to set up new patients and apply payment to the appropriate patient's account.
- Post and reconcile insurance and patient payments, research and resolve incorrect payments. EOB rejections, and other issue with outstanding accounts.
- Insure accuracy of insurance claims. Verify correct ICD-9, ICD-10 and CPT codes for a variety of specialties.
- Appealing and negotiating payments with insurance company's behalf of doctors.
- Monthly processing of patient statement.
- Answer and resolve patient billing inquiries.
6-10 years of experience
Currently assigned to processing Member Submitted Claims for the Workers Compensation business unit.
- Assist the Department of Defense Manual Claims business unit with processing of claim(s).
- Accurately input member data; prescription documentation into company computer system.
- Determine Network/Retail Pharmacy Options; Ancillary Charge; Pharmacy Submit/Third Party Submit Paper Bill Reimbursement; Mail Order.
- Investigate any/all rejections that occur during process.
- Note in computer system any prescription needing to be returned to the member for customer service call center inquiries.
- Resolve complex claim issues via Houston Service Requests.
- Communicate with the client Account Management team on a daily basis pertaining to claim processing and prior authorization requests.
- Manage performance guarantees for both the client and members.
- Identify drug form, type and strength to manually determine correct National Drug Code number value which will allow claim to reimburse accordingly.
0-5 years of experience
- Provide high-quality customer service
- Claim Investigation-Initial investigation and evaluation of appropriate resource identification/assignment completed within 3 business days of receipt of claim
- Ensure medical evidence is submitted within 10 workdays from the date the employee claims continuation of pay (COP) or the date the disability begins or recurs
- Maintain worker's compensation tracking log
- Maintain personal contact with injured claimant
- Contact medical providers for updates on injured worker's status
- Update customer on claim status
- Bring claims to closure
0-5 years of experience
- Comply with current federal claim regulations while improving the claim process to increase efficiency.
- Gathered feedback from team members to implement a new claim and training process.
- Worked with manager to create first steps in building a FHA claims queue.
0-5 years of experience
Facility and Hospice Billing
- Claim Specialist
- Maintain Patient accounts and records.
- Creating Excel Spread Sheets to track payments and company growth.
- Maintaining a growing knowledge of insurance guidelines and medical equipment.
6-10 years of experience
- Completes thorough and timely investigations of motor vehicle accidents
- Utilizes knowledge of auto policy to resolve coverage questions
- Provides remarkable customer service
- Identifies insurance fraud and resists payment of non-meritorious claims
- Discusses litigious strategy with defense counsel
0-5 years of experience
- Applies all appropriate provisions of the disability contract to ensure that [company name]'s liability is understood and appropriately applied throughout the life of the claim. Within the context of liability, encourage and support return to work through a variety of programs and methodologies
- Proactively communicates with the claimant to set expectations, assess medical and non-medical barriers to return to work, and keep him or her fully aware of the status of the claim
- Partners with the claimant, Nurse Clinicians, Psychiatric Clinical Specialist and more experienced resources to ensure that each claim has a well-understood plan that is appropriate for the unique situation of each claimant, his or her functional capacity and the prognosis for an increase in that capacity
- Facilitates team meetings, provides organizational goals and updates, outline team current metrics and team expectations
- Provides training covering STD/FMLA background, objectives, and navigation through the scripts to all team members as well as conducted training for new hires
10+ years of experience
- Consistently delivers a remarkable customer service experience through handling claims involving injury, including fatalities.
- Investigates, evaluates, negotiates, and settles auto claims in an assigned area to include verification of coverage, legal liability and extent of damage to persons and property, which may require contact by telephone, correspondence, in person, or various electronic media.
- Applies a knowledge of policies, procedures, laws, statutes, and insurance regulations when determining coverage, liability, damages of injury (first and third party) and property damage.
- Recognizes and reviews claims requiring specialized handling, including identifying issues that may require the use of independent experts or vendors.
0-5 years of experience
- Manage complex and problematic high visibility worker's compensation claims within company standards and best practices.
- Handle claims consistently within accordance any statutory, regulatory, and ethical requirements.
- Investigate and gather information through communication with the injured worker, the employer and medical care givers.
- Determine validity, potential subrogation, and compensability of claims along with the benefits due to the injured worker.
- Develop and manage well documented plans of action, expressing the proper strategy to appropriately bring the claim file to closure.
- Build a report with our injured worker and maintain professional customer relationships through communication on claim status updates given verbally, e-mail and official written documents sent via United States Postal mail.
- Authorize necessary medical treatment, diagnostic test and durable medical equipment to insure injured workers receive the proper care to successfully heal from their work related injury.
- Compute the financial benefits that are due to eligible claimants.
- Collaborate with the Return to Work Coordinator and Case Managers to bring about early return to work efforts.
- Mentor less tenured associates.
10+ years of experience
- Review claims for validity; coordinate documentation and information with law enforcement agencies.
- Monitor investigation to ensure proper executions of company procedures.
- Attended trials, hearings and depositions. In charge of negotiations, estimates and settlements of claims.
- Rule out any fraud along the way.
- Maintain company security in handling sensitive claims and documents.
- Prepare written reports to submit to company attorneys in preparation for trial.
- Testify in court on behalf of the company.
- Participate in developing strategy for outreach and communication with members of Congress, and other government entities around selected issues, including the supervision of consultants at the federal level and in the relevant states.
0-5 years of experience
- Investigate, evaluate, negotiate and settle auto claims to include verification of coverage, legal liability and extent of damage to vehicles and property.
- Evaluate and settle auto total loss claims according to three different state law, legislation and compliance regulations.
- Apply knowledge of policies and procedures when determining coverage and concluding claims while having access to and monitoring confidential information.
- Use in-depth knowledge of liability issues to handle complex claims.
- Communicate with insureds, claimants, witnesses, agents, insurance companies, repair shops, and attorneys in the course of conducting investigations.
- Recognize and properly handle subrogation and salvage issues on claims.
- Serve as a resource and single point of contact to assist in the training and coaching of other State Farm associates on claim related issues.
- Develop job aides and resource materials for team members and management.
0-5 years of experience
- Process disability claims for STD, LTD, ABS
- Claim perfection processing
- Faxing, sending correspondence (electronic), emailing
- Gathering information needed for processing claims and calling clients
0-5 years of experience
- Final review of [company name] files before submitting to HUD
- Worked in HERMIT system to insure the balances were within tolerance
- Reviewed title for open liens
- Reviewed appraisals to insure that repairs were completed if necessary
- Reviewed 1st and 2nd mortgage for correct loan amount
- Verified Occupancy
- Verified taxes and insurance were current and paid
- Packaged files to be submitted to HUD for purchase
0-5 years of experience
- Opening Cases for all our offices around South Florida.
- Prepare, compile, and sort documents for data entry.
- Check source documents for accuracy, running conflicts with InterWeb Software System.
- Verify and correct data where necessary search for further information for incomplete documents.
- When case is cleared, enter data from source documents into ATO Software System.
- File documentation with the court.
- Complete case set up with the system.
6-10 years of experience
- Selected for specialty unit assigned exclusively to work liability claims.
- Interview claimants, witnesses, police, physicians, and other relevant parties to determine claim settlement.
- Compose detailed reports on policy coverage.
- Review police reports, medical records, and physical property damage to determine the extent of liability.
- Negotiate claim settlements and manage litigation when settlement cannot be negotiated.
- Identify and monitor for possible fraud throughout the course of the claim.
- Experienced in claimant, attorney, and litigation representation.
- Mentor and train incoming employees.
0-5 years of experience
- Gather and process information needed to complete medical insurance claims.
- Make and received calls via telephone or email to health care providers with questions regarding claims.
- Assist with processing routine claims, investigate pending claims and resolve discrepancies.
0-5 years of experience
- Provide Benefits to Providers & Members.
- Provide Claim Status of processed Claims and adjusted/corrected claims as needed for both providers and members.
- Handle claims meeting Express criteria, engage team leads as needed, and route claims to other segments.
- Utilizes the applicable job aids, expertise, and tools to process and document
- Gather information and explain coverage and claim processes on liability,
- Help resolve and have FFM Marketplace files updated.
- Make outbound calls on HICS cases via CMS.
- Respond to incoming Emails and voicemails received from members.
6-10 years of experience
- Successfully manage Litigation Claims for our non-serviced states (Massachusetts, Louisiana, Canada, Alaska, Hawaii) and large loss/complex employee matters that occur anywhere in the Country. Matters include Casualty, Homeowners, Property, Material Damage and Commercial.
- Cover managers desk when they are out of the office (includes addressing complaints, customer concerns, Associate questions and approval or denial of financial authority for other adjusters).
- Oversee and direct multiple Defense Attorneys in numerous venues to make sure they are properly defending our member's and that they are complying with Best Practices, our litigation plans and expense budgets appropriately.
- Effective use of DPS/AIS for bill reviews.
- Present large loss and high exposure matters to upper leadership.
- Work with Office of General Counsel and Assistant General Counsel across the country.
- Maintain Continuing Education credits and insurance licenses in all states where required.
- Research and analyze policies and Jurisdictional overviews.
- Resolve large loss/litigation files in compliance with insurance laws, regulations, state and international (Canada) requirements.
0-5 years of experience
- Help customers with auto claims in the property damage division
- Process and monitor workflows for auto claims
- Negotiate and settle claims in the bodily injury division