Claim Representative Resume Samples

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Claim Representatives intermediate between insurance companies and their customers; these employees determine whether the loss is covered or not. Essential job responsibilities of a Claim Representative include assessing damage, interviewing customers, negotiating payments with customers, authorizing payment or denying the claim, and investigating customer background. Based on our collection of example resumes for Claim Representative, main job requirements are knowledge of insurance claim procedure, analytical thinking, decision making, confidentiality, integrity, and an investigative nature. Employers select resumes displaying a degree in insurance and risk management.

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1

First Party Medical Claim Representative

Represented claims related to injury treatment and medical administration. Managed Personal Injury Protection and Medical Payment Coverage claims from inception through completion. Accountable for providing accurate and timely medical billing payments. Solved customer challenges with professionalism and diligence. Acted as liaison between policyholders and provider offices to ensure accurate processing of claims. Maintained Reservation of Rights Correspondence to allow further investigation of designated claims.

  • Extensively negotiated medical management investigations involving multiple insurance providers.
  • Conducted Pro Rata mediations when policy limits became exhausted.
  • Prepared and delivered denial and acceptance correspondence to policyholders.
  • Interacted with Medicare and Medicaid representatives to report claim activity.
Candidate Info
12
years in
workforce
2
years
at this job
Associate
2

Claim Representative

  • Investigated, evaluated, negotiated and settled total loss auto claims to include verification of coverage, and extent of damage to vehicle property damage, which may require contact by telephone, e-mail, and correspondence, in person or other electronic media.
  • Applied knowledge of policies, procedures, law, statues and insurance regulations when determining coverage, and property damage. Determined whether additional or specialized investigation is necessary for claim resolution.
  • Informed agents as needed during the claims process to ensure all proper procedures, and coverage explained to facilitate a seamless claim settlement.
  • Used various electronic resources, such as Mitchell, CCC, and Autosource for total loss settlements.
  • Identified and implemented solutions to achieve goals set for the Total Loss and Subrogation segments, while supporting Company objectives.
  • Communicated with, Lien holders, storage yards, law enforcement officials, and internal departments to resolve claims.
  • Interpret State titling laws and regulations as it applies to the auto industry.
Candidate Info
26
years in
workforce
12
years
at this job
C
Certificate
C
Certificate
3

Claim Representative

  • Strategized and conducted investigations of claims of moderate to complex claims, confirmed or denied coverage in accordance to insurance policy contracts
  • Assimilated data, evaluated, and negotiated the settlement of total loss claims to reach a reasonable and just settlement
  • Prioritized and handle multiple tasks simultaneously while maintaining an effective follow-up system on over 200 pending files.
Candidate Info
17
years in
workforce
8
years
at this job
BS
Business Administration / Management
4

Fire Casualty Field Claim Representative

  • Conducted coverage and liability investigation and applying relevant state statues and policy language.
  • Conducted scene investigation and recorded interviews with policyholders, claimants, and witnesses to determine liability.
  • Handled and resolved complex coverage and liability claims with minimal supervision and recommended appropriate resolution to management.
  • Prepared written communication including coverage memos, evaluation reports, and letters.
  • Evaluated and negotiated fair and equitable settlements of bodily injury claims with claimants and attorneys.
  • Investigated, evaluated, and assisted defense attorney on litigation claims including attending depositions, arbitrations, mediation, and trials.
Candidate Info
24
years in
workforce
4
years
at this job
BBA
Accounting
5

Catastrophe Claim Representative

  • Successfully resolved catastrophic losses with policy holders in several states, as well as Canada, while working with unfamiliar managers and staffing from across the country at each location.
  • Accurately estimated losses on properties ranging from thousands of dollars to multi-million dollar estates.
  • Continually obtained above average performance reviews.
  • Developed a claim handling tool to help accurately record flood loss information after hurricane Katrina resulting in faster payments to claimants, increased policy holder satisfaction and reduced staffing expenses.
  • Utilized as a team leader/trainer from 2004 through 2007 due to functional and technical expertise.
  • Considered by management as a key dispute resolution resource.
  • One of twelve claim representatives selected from sixteen hundred to attend and provide feedback at State Farm's Catastrophe Management Strategy meetings held in Las Vegas.
  • Wrote an Excel calendar program to track deployments and monitor employee benefits usage.
Candidate Info
19
years in
workforce
10
years
at this job
BA
Criminal Justice / Sociology
6

Special Claim Representative

Handled 150-200 bodily injury units. Interviewed all parties involved such as: claimants, insured's, witnesses, law enforcement officials, physicians, and attorneys. Obtained written and recorded statements.

  • Review client's medical records to ensure that all conditions of care, operations, and procedures are properly documented.
  • Review medical records and consulted with medical providers to determine injuries are related to motor vehicle accident.
  • Referral to independent medical examiners (IME's) for further file handling of bodily injury claims.
  • Review property damage reports and photos to determine extent of company's liability and mechanism of injury in relation to motor vehicle damage.
  • Educate providers through feedback, informal meetings and assisted in training new personnel assigned to the department.
  • Successfully negotiated bodily injury settlements either by meeting face to face or via telephone.
  • Authority to make decisions independently as well as, with a claims committee.
Candidate Info
21
years in
workforce
10
years
at this job
BS
Political Science
7

Auto Blend Claim Representative

Handles 1st and 3rd party Personal Auto Damage, First Party Medical, and Bodily Injury Liability claims.

  • Provide quality claim handling throughout the claim life cycle.
  • Maintain oversight of the repair process and ensure appropriate expense handling.
  • Investigate each claim to obtain relevant facts necessary to determine coverage.
Candidate Info
3
years in
workforce
8
months
at this job
BS
Business Administration
International Business And Operations Management
8

Claim Representative

  • Interpret and make decisions using independent judgment on more complex and unusual policy coverages.
  • Manage all aspects of investigative activity on complex claims. Direct the litigation strategy with legal counsel.
  • Analyze claims and prepare reports for clients/carriers and management.
  • Establish reserves, and authorize payments within scope of authority and settle claims in the most cost effective manner.
  • Develop subrogation and third party recovery potential.
Candidate Info
13
years in
workforce
2
years
at this job
AS
Associate of Science
BS
Organizational Management
MA
Leadership
9

Claim Team Manager, Claim Representative

  • As the first line supervisor of 16 Claims Representatives, maintain responsibility for performance management and performance reviews. Trained the representatives to understand, track, and correctly identify overpayments.
  • Spearhead investigation, evaluation, negotiation and resolution of property damage and bodily injury claims including writing estimates.
  • Accurately determine coverage, liability and damages. Analyze and investigate claims to ensure documentation is complete and accurate. Verify insurance eligibility and troubleshoot third party claims, identify billing errors and demonstrate expertise in adjusting claims.
  • Complete internal reports and comply with all internal policies and procedures. Maintain an advanced understanding of relevant statues, case law and medical terminology.
  • Document claim files accurately and in a timely fashion. Maintain an advanced understanding of all company policy coverages. Initiate team meetings to study complex policies, claims and high-risk exposures.
Candidate Info
8
years in
workforce
7
years
at this job
AS
Claims
BS
Business Management
10

Claim Representative

  • Assisting with the process of claim adjudication, ensuring that eligibility referral/authorizations, and payments are appropriate.
  • Ensuring that all mandated government and state regulations are consistently met.
  • Taking the responsibility for claims denial process, with appropriate communications to members, providers and carriers. Ensuring all Customer Service inquiries are distributed and processed.
  • Verifying correct enrollment numbers and mailing completed agreements to proper payer/vendor for approval.
  • Working prebilling and production reports associated with new providers, products and services.
  • Assisting with policies and procedures essential to the setup of new providers, products and services.
  • Provided guidance to hiring managers on interviewing best practices.
  • Completing the enrollment process and sending paperwork to client.
  • Verifying payer IDs on Master Insurance list/ Special projects as assigned.
Candidate Info
17
years in
workforce
3
years
at this job

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