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Claim Specialist Resume Samples
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Candidate Info
31
years in workforce
10
years at this job
BS
Science / Business
Customer Service Manager / Insurance Claim Specialist
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.
Candidate Info
14
years in workforce
1
year at this job
Associate
Complex Property Damage Claim Specialist
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.
Candidate Info
29
years in workforce
4
years at this job
BA
Criminal Justice / Sociology
Claim Specialist
- 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.
Candidate Info
27
years in workforce
1
year at this job
AS
Applied Science
Quality Assurance Claim Specialist II
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.
Candidate Info
31
years in workforce
2
years at this job
HS
High School Diploma
AAS
Associate of Applied Science
Claim Specialist
- 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
28
years in workforce
24
years at this job
AS
Supervision Technology
BA
Bachelor of Arts
Claim Specialist
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.
Candidate Info
5
years in workforce
2
years at this job
HS
High School Diploma
BS
Business Administration
Short Term Disability Claim Specialist
- 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.
Candidate Info
3
years in workforce
1
year at this job
AS
Business
Claim Specialist
- 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
Candidate Info
4
years in workforce
BA
African American Studies
Claim Specialist
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.
Candidate Info
8
years in workforce
5
years at this job
BA
Communication
Claim Specialist
- 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
Candidate Info
10
years in workforce
2
years at this job
BA
Forensic Criminal Investigation
Claim Specialist
- 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
Candidate Info
9
years in workforce
3
years at this job
BA
Finance And Management
Claim Specialist
- 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.
Candidate Info
15
years in workforce
1
year at this job
HS
High School Diploma
Technical Claim Specialist/authorizations
- 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
Candidate Info
41
years in workforce
32
years at this job
AS
Law Enforcement
BS
Bachelor of Science
Claim Specialist
- 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
Candidate Info
12
years in workforce
7
years at this job
HS
Georgia Mortgage Compliance
C
Mortgage Finance
Claim Specialist
- 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.
Candidate Info
5
years in workforce
1
year at this job
Tourism And Hospitality
Claim Specialist
- 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
Candidate Info
6
years in workforce
2
years at this job
BA
Psychology
Claim Specialist, Fidelity Medical Billing
- 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.
Candidate Info
11
years in workforce
6
years at this job
AA
Business Administration
Claim Specialist
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.
Candidate Info
7
years in workforce
7
months at this job
BS
Sport Management
Workers Comp Claim Specialist
- 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
Candidate Info
13
years in workforce
2
years at this job
Government Claim Specialist
- 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.
Candidate Info
4
years in workforce
3
years at this job
Administrative Assistant/accounts Receivable Clerk/claim Specialist
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.
Candidate Info
6
years in workforce
6
years at this job
BS
Criminal Justice
Enterprise SIU - Multi Claim Investigative Unit Claim Specialist
- 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
Candidate Info
8
years in workforce
3
years at this job
AS
International Business
BA
Management
MS
Labor Relations
Std/fmla Claim Specialist
- 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
Candidate Info
39
years in workforce
11
years at this job
License
Claim Specialist
- 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.
Candidate Info
11
years in workforce
11
months at this job
BS
Political Science
Senior Claim Specialist
- 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.
Candidate Info
35
years in workforce
31
years at this job
BS
Criminal Justice
Claim Specialist
- 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.
Candidate Info
10
years in workforce
5
years at this job
BA
Business Administration
MA
Human Resource Leadership
Business / Business Technology / Marketing Teaching
Auto Claim Specialist
- 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.
Candidate Info
15
years in workforce
4
months at this job
AA
Pre-nursing
BS
Health Promotion
Claim Specialist
- Process disability claims for STD, LTD, ABS
- Claim perfection processing
- Faxing, sending correspondence (electronic), emailing
- Gathering information needed for processing claims and calling clients
Candidate Info
9
years in workforce
2
years at this job
BS
Criminal Justice
Paralegal Studies
Claim Specialist
- 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
Candidate Info
6
years in workforce
2
years at this job
Certified Billing And Coding Specialist
PIP Claim Specialist/data Entry/file Clerk
- 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.
Candidate Info
20
years in workforce
9
years at this job
BS
Business Administration
Claim Specialist - Property and Casualty
- 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.
Candidate Info
5
years in workforce
6
months at this job
AS
Health Care Administration
Claim Specialist
- 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.
Candidate Info
16
years in workforce
2
years at this job
Business Administration
Medicare, Exchange/commercial Benefits & Claim Specialist
- 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.
Candidate Info
31
years in workforce
8
years at this job
AS
Business Administration
BA
Business Administration
Claim Specialist III, Litigation, SPECRO
- 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.
Candidate Info
27
years in workforce
5
years at this job
BS
Computer Systems
Claim Specialist / Claim Representative
- 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
Claim Specialist Resume Success Stories
