Claim Examiner Resume Samples

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Claim Examiners determine whether payments and settlements have been made suitably for settled insurance claims. Essential job duties highlighted on a Claim Examiner resume sample are maintaining claim files, making sure claims are valid, authorizing payments, discussing cases at committee meetings, and consulting specialists for additional information. Those interested in a Claim Examiner career should be able to mention the following skills in their resumes: knowledge of insurance issues, accuracy, decision-making, integrity, effective communication, and recordkeeping. Claim Examiners come from various educational backgrounds and are trained on the job.

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1

Sr. Claim Examiner

  • 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
Candidate Info
27
years in
workforce
3
years
at this job
HS
High School Diploma
AAS
Associate of Applied Science
2

FMLA Claim Examiner

  • Adjudicated assigned caseload of Integrated FMLA and Short Term Disability claims by interacting with internal and external customers (i.e. claimants, employers, physicians, physical therapists, and attorneys) in order to obtain information necessary to make the decision on a claim, determine the benefit duration period or reason for denial, mail all necessary correspondence and maintain consistent follow up, and determine an appropriate return to work date while adhering to policy/client specific handling and customized process.
  • Demonstrated independent and effective claim/block management by evaluating risk in decision making and benefit period duration with various resources, such as Medical Disability Advisor, clinical claim discussions with physicians and registered nurses, Vocational Resource Consultants (VRC's), SOP's, intranet job aids, and ICD-9 coding.
  • Actively discussed, encouraged, and coordinated claimants returning to work as soon as possible by utilizing various available accommodations, speaking to physicians and claimants to obtain recovery status and ability, advising claimants to adhere to their set treatment plan, and reminding them of the various benefits of returning to work.
  • Understood and complied with all applicable laws, regulations, and procedures demonstrated by the application of ERISA, HIPAA, state mandates for claim adjudication, and adherence to SOP's and Best Practice claim handling.
Candidate Info
8
years in
workforce
1
year
at this job
BS
Business Administration
3

Medical Claim Examiner

To maintain good relation with the providers. Reporting the claim error, if any, by daily audit report or paper tracking. Adjustment on the claims, processed medical claims, encounters, good customer service, maintain heavy telephoned calls. Computed total medical bills showing amounts to be paid by insurance.

  • Calculated amount of claim
  • Transmitted claims for payment and further investigation
  • Posted and attached information to claim file
  • Reviewed insurance policy to determine coverage
  • Investigated the matter with care and attention
  • Notified claimant of denied claim and appeal rights
  • Determined existence and amount of liability
  • Collected all applications and investigated all claims received from insured customers
Candidate Info
10
years in
workforce
6
years
at this job
C
Collector
C
Medical Assistant
4

Claim Examiner

Handle medical only workers' compensation claims, analyzing them to determine extent of carrier's liability.

  • Monitors and coordinates medical treatment to ensure appropriate return to work.
  • Ensures that claim file documentation and reserves are current; keeps employer advised on claim status.
  • Responsible for completion of state mandated filings.
Candidate Info
10
years in
workforce
3
years
at this job
Music Education
5

Claim Examiner

  • Responsible for independently reviewing claim documents for flood.
  • Tracked claim process and policy for FEMA requirements
  • Assisted with making coverage decisions based upon SFIP
Candidate Info
9
years in
workforce
1
year
at this job
6

Sr. Claim Examiner

  • Examine Inpatient, outpatient Skilled Nursing facility claims for processing
  • Process High dollar claims for all Line of Business
  • Knowledge of California DOFR
  • Reverse Void and Adjust claims for all Line of Business
  • Process Market Place MMP and Medicare claims
  • Process Stop loss, Per Diem, DRG and Case Rate claims
  • Handle all inbound calls regarding claims and appeals
  • Research claims for non/incorrect payment
  • Request and submitted EOB
  • Assist MMP members with claims payment inquirers
Candidate Info
12
years in
workforce
5
years
at this job
C
Medical Billing
AS
Healthcare Office Administration

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