Claims Examiner Resume Samples

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Claims Examiners contribute to the final decision on covering losses from accident or illness. Key activities mentioned on a Claims Examiner resume are preventing insurer financial loss, assessing insurance claim validity, reviewing investigator findings, checking documentation, and making sure company guidelines are being followed. Based on our collection of resume samples, the ideal candidate should demonstrate insurance claim expertise, attention to details, strong communication abilities, report writing skills, and computer competencies. Most Claim Examiners hold a Bachelor's Degree in a legal or business related field.

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1

Claims Examiner

Analyze claims to determine appropriate benefits in accordance with policy provisions. Collaborated with insurance representatives and claimants to substantiate coordination of benefits order. Prepared and maintained accurate documentation to support legal subrogation claims and work compensation intervention files. Adhered fully to all HIPAA compliance guidelines. Used MS Excel to track and monitor claims progress, payment refunds, and file closure.

  • Identified and resolved potential billing errors with medical service providers which resulted in cost savings.
  • Relied on by management to assist with claims processing for various claim groups administered by Zenith from across the country because of my ability to quickly understand various benefit plans and procedures.
  • Tested the effectiveness of claim system conversions to validate the accuracy of claim system data and processing.
  • Provided formal correspondence to respond to a complicated regulatory complaint.
  • Demonstrated ability to meet service and quality requirements while working from remote locations without direct supervision.
Candidate Info
14
years in
workforce
14
years
at this job
C
Medical Secretarial
2

Claims Examiner

Handled over 175 claims files of personal injury and property damage claims for first and third parties

  • Investigated coverage, evaluate, negotiated and settle auto liability claims
  • Reviewed files and send them to recovery or SIU
  • Trained and mentored 10 new hires
  • Received ACE award for customer service
  • Received Special Unit Investigation Award
  • Highest percentage in referral to the subrogation unit in 2005
Candidate Info
9
years in
workforce
5
years
at this job
All Lines Claims Adjuster
3

Senior Claims Examiner

  • Manage and delegate tasks to team of 8 direct reports.
  • Provide problem resolution expertise in matters of errors and reconciliation.
  • Developed and implemented a newborn report to automate and streamline the clearances process and significantly reduce enrollment and claims timelines.
  • Designed and launched a batch status report resulting in department-wide backlog reduction.
Candidate Info
28
years in
workforce
3
years
at this job
BA
Public Administration & History
4

Claims Examiner

  • Assigned reserve values to claims, made claims payments as necessary and settled claims up to designated authority level.
  • Ensured claim files are properly documented and claims coding is correct.
  • Preserved confidentiality of all claims files, claims reports and claims-related issues.
  • Resolved complex and severe exposure claims using high service oriented file handling.
  • Maintained professional client relationships; resolved client issues.
Candidate Info
8
years in
workforce
8
months
at this job
C
Complete Artistic Pro Specialist
BS
Business Administration
5

Claims Examiner II

Analyze moderate to complex workers' compensation claims to determine benfits due. Use established analytical and investigative techniques to conduct investigations to properly set reserves for moderate to high exposure claims involving litigation and vocational rehabilitation. Routinely audited files for payment accuracy within policy and state guidelines while ensuring ongoing adjudication of claims within company standards, industry best practices and client specific requirements.

  • Thorough and timely investigations to determine liability and loss exposures with excellent attention to details.
  • Assisted and delivered on client specific metrics and requirements on an ongoing monthly basis while maintaining high file quality audit scores.
  • Assisted and aided management with providing mentoring to new employees to the team.
  • Outstanding organizational, oral communication and interpersonal skills to work with client representatives and customers in stressful and crisis management situations.
Candidate Info
10
years in
workforce
5
years
at this job
BA
Political Science
6

Claims Examiner

Edited and wrote procedural documents for claims examiners and transition project

  • Examined and resolved issues with health insurance claims
  • Reviewed and responded to incoming provider and member correspondence
  • As home processor, coordinated work with local and Ohio offices via internet
Candidate Info
8
years in
workforce
4
years
at this job
C
Technical Writing And Editing
BA
English
7

Medical Claims Examiner

Processed different types of claims such as: Medical, DME, Home Care, SNF and Surgery

  • Knowledge of EPO, HMO, PPO, POS, Medicare and Medicaid
  • Consistently exceeded production and quality standards, maintained 99% financial and 98% procedural accuracy
  • Ability to work in multiple and special queues such as Optum claims as well as identifying system issues during implementation of HIX processing
  • Primary claims examiner during implementation of HIX processing
Candidate Info
8
years in
workforce
2
years
at this job
C
Computerized Office Technology
Medical Billing And Coding Graduate
8

Claims Examiner

Speak with clients in a customer service call center environment regarding their various individual life insurance policies and update required information

  • Explain benefit coverage, documenting, and investigating claims from beginning to end.
  • Receive calls from beneficiaries regarding recent and outstanding death notifications and answer any related questions
  • Communicate with clients effectively and professionally
  • Offer excellent customer service by providing complete and accurate information to clients in a multi-task, high-pressure environment that requires attention to detail
  • Meet and exceed production, attendance, quality and service goals
  • Follow proper client and state regulations to ensure compliance with appropriate guidelines
Candidate Info
5
years in
workforce
3
years
at this job
AA
Associate of Arts
BS
Communication
9

Medical Claims Examiner

  • Performed complex rule based data conversions and worked across different areas within the Healthcare and Insurance domain
  • Properly adjudicated claims bases on my knowledge of covered benefits, insurance and provider contracts
  • Interpreted and analyzed client data to add, delete, modify data and also find solutions to individual client problems based on moderately complex to complex business rules
  • Ensured accurate and timely completion of transactions to meet or exceed client service level agreements
  • Identified and resolved both regular and non-routine issues
  • Ability to analyze and process transactions, with a strong understanding of Claims
  • Applied Healthcare and Insurance domain knowledge, theoretical concepts, etc. to undertake problem solving
Candidate Info
9
years in
workforce
1
year
at this job
BS
Health Studies
MBA
Health Systems Management
10

Property Damage Claims Examiner II

  • Investigated and adjusted moderately complex third party auto damage claims presented by or against our renters to ensure claim validity, legal liability and settlement value.
  • Established and monitored appropriate claim reserves. Evaluated and negotiated settlement of claims within established settlement authority limits.
  • Reviewed loss reports, confirmed coverage, explained procedures, issued claim payments and answered inquiries for auto claims.
Candidate Info
7
years in
workforce
2
years
at this job
Communication

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