Claims Examiner Resume Samples - Page 2

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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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11

Claims Examiner

Established strong rapport with agents and customers

  • Successfully handled catastrophe claims and injuries
  • Determined liability and processed 1st and 3rd party claims
  • Prepared files for litigation
  • Handled all claims timely to mitigate damages and cost
Candidate Info
11
years in
workforce
7
years
at this job
BS
Human Services
12

Claims Examiner

  • “Cradle to grave” senior level claim processing for multiple large accounts in a variety of industries for both Oregon and Washington. Processing duties included complying with client, [company name] and jurisdictional requirements, appropriate and timely assessment and payment of claim benefits, thorough investigation of claims for compliance, 3rd party liability evaluation and subrogation recovery, and resolution of litigated issues while working one on one with defense attorneys.
  • Two time colleague of the month
  • 4th Quarter 2014 Values In Action Honoree
  • Successful completion of the Industry Advancement Program at the top of my class.
  • Current Washington and Oregon Claims Examiner Certification, with prior training in CA processing.
  • Company recognition for exception audit scores over 90%
  • Founding member of the “Claim Staffing Roundtable”
Candidate Info
17
years in
workforce
8
years
at this job
HS
High School Diploma
AA
Associate of Arts
BS
Biology
13

Claims Examiner

Completed and overseen a variety of professional assignments to manage a caseload of disability claims by reviewing new claims to determine the validity of claims, ascertaining proper filings, identifying the need for further investigations, and following claims through closing or settlement.

  • Obtained relevant medical records and statements from the treating physician.
  • Monitored on-going medical treatment for progress and refers claimants for independent medical evaluation.
  • Ensured file was kept current to reflect all appropriate forms, statements, and reports.
Candidate Info
8
years in
workforce
2
months
at this job
Business
14

Senior Claims Examiner

Handled all claims for members and providers in an efficient and professional manner while meeting and exceeding all departmental production standards effectively

  • Ability to make claim payment/denial decision in a timely and accurate manner based on members benefits and eligibility
  • In-depth knowledge with ICD-9 codes, HCPCS, CPT and revenue codes
  • Dedicated units: Non-participating, durable medical equipment, coordination of benefits specializing in standard and non-duplication methods
  • Processed [company name], GEOBlue, and Independence Administrators Local and Blue Card hospital and physician claims
  • Blue Squared knowledge to obtain other party liability values from other carriers for processing coordination of benefits and MVA claims
Candidate Info
9
years in
workforce
1
year
at this job
15

Claims Examiner II

Review and process claims/encounters based upon eligibility, benefits, authorizations and contractual agreements between the HMO and providers.

  • Responsible for adjudication of Encounter claims with a daily production of approximately 150 claims per day. Duties also include adjudication of fee for service claims and maintaining production standard of professional and hospital claims per day with an error ratio of no greater than 5%.
  • Responsible for timely resolution of pended claims according to department's compliance standards.
  • Identify and notify Claims Manager or Claims Lead of system related issues.
  • Assist of departments in research of claims, authorization and adjustments, if necessary.
  • Thoroughly review potential duplicate claims submission. Provide detail research on Third party liability cases (TPL), financial responsibility claims of another payer that have been mistakenly paid, or claims paid at the incorrect reimbursement rate.
  • Perform other tasks delegated by Claims Management and or Claims Lead.
Candidate Info
10
years in
workforce
1
year
at this job
Information Management
16

Claims Examiner

Analyze and process Workers' Compensation claims by investigating and gathering information to determine the exposure on the claim.

  • Negotiate the settlement of claims up to designated authority level and make claim payments.
  • Manage claims through a well-developed action plan to bring claim to an appropriate and timely resolution.
  • Report claims to the excess carrier, respond to requests of directions in a professional and timely manner.
  • Coordinate vendor referrals for additional investigation and/or litigation management.
  • Consistently maintain professional client relationships.
Candidate Info
7
years in
workforce
2
years
at this job
BA
Bachelor of Arts
MA
Human Resource Management
17

Senior Claims Examiner

  • Consistently maintained one of the highest rates of monthly decisions on a team of 10 claims examiners.
  • Volunteered for mentoring opportunities including customer service and LTD new hire shadowing.
  • Maintained excellent customer service by regularly exceeding time service, referrals, inventory, and training standards.
  • Demonstrated superior customer service and claims decision-making as the sole claims examiner over a prominent group of southern California national accounts.
  • Investigated and determined outcome of disability claims with sound and impartial judgment.
  • Facilitated effective transition of a short-term disability claim to a long-term disability claim.
  • Interacted directly with claimants, policyholders, attorneys, and physicians.
  • Practiced effective claims management by identifying rehabilitation opportunities and settlement candidates.
Candidate Info
4
years in
workforce
3
years
at this job
AA
Communications
BS
Meteorology
MS
Atmospheric Sciences
18

Claims Examiner

Reviewed medical claims, investigated coordination of benefits, and processed claims per coverages

  • Analyzed claims to see if medical records are needed and requested necessary records
  • Examined incoming medical records and sent appropriate records on to medical review unit
  • Processed payment or denial of claim and ensured that necessary correspondence was sent to both member and provider
  • Met individual and department standards with regards to both quality and productivity goals
  • Entered personal information, claims information, and other data related to the claim
  • Promptly processed the members' claims within the time frame of our contracts
  • Preserved confidentiality of all claims files, claims reports and claims-related issues
Candidate Info
12
years in
workforce
2
years
at this job
BA
Bachelor of Arts
19

Claims Examiner

  • Accurately process medical claims in accordance with company policies and procedures
  • Review suspended claims daily to ensure all appropriate documentation has been completed prior to processing
  • Review audit results weekly, correcting errors in the claims processing system within designated timeframe
  • Maintain performance standards for accuracy and production
  • Participate in all training sessions as recommended to remain current on all departmental policies and procedures
Candidate Info
10
years in
workforce
2
years
at this job
HS
High School Diploma
20

Claims Examiner

Reviewed property claims

  • Determined settlement and coverage of claims
  • Provided customer service
  • Managed large caseload
Candidate Info
14
years in
workforce
1
year
at this job
Music Studies

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