Claims Examiner resume examples

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Skillful Claims Examiner resume

RAYMOND J CAREY
Summary

Seeking a Claims Examiner position in which the employees are team workers whose aim is Success, while contributing to the goals and objectives of the employer.


Experience
Zurich North America Disability Insurance Plantation, FL Claims Examiner II 02/2017 to Current
  • Assess policy details to determine accurate coverage interpretation.
  • Completed high detailed investigation on each claim in a timely manner and fully document the file with pertinent information. 
  • Prepared appropriate coverage letters to be submitted to and approved by claims management. 
  • Maintained consistent contact with involved parties to keep all informed of claim progress. 
  • Set accurate reserves on each claim within given authority level and promptly bring claims that will require reserves in excess of their authority to their supervisor's attention. 
  • Maintained documentation system that assures that each assigned claim will receive necessary ongoing attention. 
  • 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.
Matrix Absence Management Inc Fort Lauderdale, FL Claims Examiner I AMS 05/2015 to 02/2017
  • Determines eligibility under federal and state requirements for leaves submitted and determines eligibility under client's plan/policy. 
  • Responds to customer service issues within required time frames.
  • Pro-actively communicates decisions within Best Practice guidelines, consistently meeting Performance Guarantee requirements. 
  • Makes claim determinations to approve, deny or delay and or reach out to additional resources for review, based on medical certification review and management.
  • Determines the duration associated with the leave and or disability based on the information given by the healthcare provider. 
  • Communicates approvals, denials, leave extensions, return to work plans and other important information regarding the leave to the employee and client. 
  • Manages leaves that are concurrent with Short Term Disability 
ARRIVA MEDICAL Coral Springs, FL Team Leader 09/2011 to 04/2015
  • Manage and monitor call volume to ensure proper call handling time.
  • Provide Key Performance Indicator (KPI's) reports to managers and supervisors daily.
  • Supervise, audit develop, train and coach agents based Quality audit reviews and department goals.
  • Issue Development Action Plans (DAP's) to agents that are not meeting department goals.
  • Interaction with all internal departments ensuring a high level of service to new and existing patients.
  • Approve and override diabetic claims on exception report. 
  • Provide support to the sales department.
     Crossed trained to assist customer service, ADR, billing and medical records department.
  • Communicate with customers and physician's office regarding incomplete Certificate of Medical Necessity (CMN).
ENVISION RX OPTIONS Fort Lauderdale, FL Pharmacy Helpline Team Leader 06/2009 to 09/2011
  • Handle daily correspondence regarding pharmacy issues from members, providers and pharmacies.
  • Enroll Medicare Beneficiaries into Part D program.
  • Educate members on Medicare and Medicaid benefits which relates to Low Income subsidy.
  • Process Pharmacy claims for Medicare part D beneficiaries. 
  • Provide support to the clinical department and health plan customers through problem solving.
  • Completing all special projects in a timely manner.
AETNA RX HOME DELIVERY Pompano Beach, FL Collection Team Lead 12/2005 to 04/2009
  • Manage and monitor call volume to ensure proper call handling time for Accounts Receivable Billing & Collections Reps and Claims  department. 
  • Address provider & Patients payment issues regarding outstanding credits and balance owed.
  • Generate past due balance extract for 30, 60 and 90 days dunning letters.
  • Assist with medication claim processing.
  • Provide regular status reports to managers regarding training, call status and monthly financial reports.
  • Supervise, Develop, train and coach staff based on call audit reviews.
Mail Order Customer service Representative 11/2005 to 11/2006
  • Responsible for servicing incoming calls from providers and members.
  • Process member request for ID cards and EOB.
  • Provide support to the Customer Service team and health plan customers through problem solving, research and resolution for prescription/pharmacy issues.
  • Account maintenance by ensuring data integrity.
Accomplishments
  • Created incentives (wheel spin and QA hall of fame) program to increase productivity and quality scores.
  • Scheduled and Coached 18 agents 5 calls per month totaling 90 calls, thus increasing the team's final monthly quality average to 96%.
Education and Training
Business 2022 Broward College, Coconut Creek, FL

Currently Enrolled

High School Diploma: General Studies 1989 Bahamas Government High School, Nassau, New Providence, Bahamas
Activities and Honors
  • AWARDS Awarded the Aetna way Excellence Award 2009
Certifications
  • 6-20/31-20 Accredited Claims Adjuster license (ACA) (Currently enrolled)
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Job-winning Claims Examiner resume

MAHALIA CLARK-WALKER
Summary
Talented Claims Adjuster emphasizing effective time management, cost control and mediation. Self-motivated and customer-focused. Insurance professional with 12 years of experience in the field of insurance with 4 years of experience as a Bodily Injury Adjuster and 8 years experience as a Property Claims Examiner.
Skills
  • Claims file management processes
  • Litigation resolution
  • Heavy litigation experience
  • Strong interpersonal and communication skills
  • Rules of evidence
  • Interviewing techniques
  • Strong interpersonal, analytical, investigative, and negotiation skills
  • Report writing
  • Property claims
  • Medical coding
  • Personal auto policy
  • Advanced knowledge of coverage, liability, and complex claims
  • Knowledgeable of state and federal laws
  • Acuity and guidewire experience
Licenses
Adjuster Licenses: Texas, Florida (Not Appointed), Oklahoma, Louisiana, Georgia, Alabama, Indiana, South Carolina
Education and Training
Dillard University- New Orleans, LA B.A. Degree in Business Administration 1981
Continuing Education Courses
Xactimate Course 2012
Property Course 2012
Personal Auto Course 2002
iia 21, 22 -  1998
Experience
State Farm Insurance Company Bodily Injury Adjuster 02/2013 to Current
  • Communicates with policyholders, witnesses, and claimants in order to gather information regarding claims.
  • Ability to handle 260 pending claims and allocate resources as necessary, and advise as to proper course of action. Responds to various written and telephone inquiries including status reports.
  • Manages, investigates, and resolves claims. Investigates and evaluates coverage, liability, damages, and settles claims within prescribed authority levels.
  • Accountable for security of financial processing of claims, as well as security information contained in claims files
  • Evaluate complex injuries which include fracture to fatilites including handling litigation assistance with in house attorney.
AAA Insurance Company Property Claims Examiner 03/2010 to 02/2013
  • Inspected damaged property and determines claims related damage. Investigated cause and origin of claims by contacting the appropriate parties including insured, claimants, agents, attorneys, contractors, other adjusters, public personnel, etc.
  • Checked for prior claims and identifies possibly suspicious claims. Estimated the cost of repair or replacement of damaged property.
  • Determined and reports on subrogation potential. Maintained the property claim workflow in order to provide customers with appropriate, accurate and timely information.
  • Resolved disputes with tact and diplomacy. Notified or directly involves the agent in the dispute resolution.Utilized arbitration, appraisal and alternate dispute resolution as needed.
  • Recognizes when assistance is needed and obtains it. Managed individual claim Inventory and meets cycle-time goals for closing files.
 
 
Q-Temps Sedgwick Claim Service - Bodily Injury Adjuster (Contract) 08/2009 to 02/2010
  • Utilized various methods of settlement in those cases where warranted; assigns cases to outside vendors as warranted.
  • Use of structure settlement on all applicable cases. Promptly and effectively handles to conclusion all assigned claims with moderate direction and oversight.
  • Makes decisions within delegated authority as outlined in company policies and procedures. Adheres to high standards of professional conduct consistent with the delivery of superior service.
  • Initiates and conducts follow-ups via proficient use of claims systems and related business systems.
  • Determines proper policy coverages, and where necessary, investigates, evaluates, negotiates and equitably settles all assigned  liability/bodily injury claims cases in accordance with company policies and procedures at values commensurate with damages sustained.
  • Opens, closes and adjusts reserves in accordance with company practices designed to ensure reserve adequacy.
  • Recommends Special Reserves where necessary. In accordance with Corporate Reserving Guidelines.  Adheres to file conferencing notification and authority procedures.
Republic Insurance Company Property Examiner - New Orleans, LA (Contract) Hurricane Katrina 08/2005 to 06/2007
  • Documented claim files and maintained control of work through documentation and a diary system. Maintained workload within department standards. Managed work product of field adjusters.
  • Responsible for approving claim files prior to returning to client.
  • Policy interpretation and ensure adherence to claim handling guidelines. Regular contact with client's claim staff to address claim specific issues.
  • Performed support functions as needed and additional duties as assigned.
City of New Orleans Sewerage and Water Board Water Remediation Adjuster 08/2003 to 10/2004
  • Expected to provide exceptional customer service while performing restorative tasks for water, fire, mold, cleaning, and other interrelated remediation assignments
  • Analyzed photos/video of extent of water damage and reviewed specialized drying and water damage company invoice for accuracy and invoices.
  • Determined determine if claimant signed Assignment of Benefit.
  • Heavy litigation from contractor attorney & claimants on high volume and crisis need claims.
  • Responsible for multiple attorney updates thru acuity and assist with specification for direction of lawsuit and or mediation.
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Experienced Claims Examiner resume

Arbria Spence
Professional Summary
Quality-focused verification specialist offering over 10 years of experience in data processing, claims and transcription.
Skills
  • Medical Terminology
  • Microsoft Office proficiency
  • Billing and coding
  • Insurance eligibility verifications
  • Claims appeal procedures 
  • Dedicated team player​
  • Strong interpersonal skills
  • Time management
  • Results-oriented
  • Meticulous attention to detail
Experience
Call Tracker Analyst
Cigna -HealthSpring Dec 2015 to Current
  • Review calls from customer service representatives regarding durable medical equipment.
  • Research plans and benefits to determine whether or not claims were paid correctly.
  • Correct incorrect information in member benefit record.
  • Responsible for auditing and processing claims where the payment exceeds $10,000.
Refund Check Analyst
Cigna Aug 2015 to Dec 2015
  • Conducted research to determine if the submitted refund or returned check is valid.
  • Composed letters to explain why return check is invalid.
  • Prepared check for deposit 
  • Conducted research to determine if checks were valid. 
Senior Claims Processor
Aug 2010 to Aug 2015
  • Processed durable medical equipment claims while assisting other team members with questions.
  • Participated in training other team members on DME claims.
  • Audited trainees claims for revision. 
Claims Examiner
Cigna Jun 2004 to Aug 2010
  • Compiled statistical information for special reports. 
  • Eliminated outdated records by sending the records to be scanned.
  • Verified that information in the computer system was up-to-date and accurate.
  • Organized billing and invoice data and prepared accounts receivable and expected revenue reports for controllers.
  • Created monthly reports for records, closed terminated records and completed chart audits.
  • Processed confidential medical claims information.
  • Successfully established effective systems for record retention by creating database for daily correspondence tracking.
Team Lead-Sprint PC
Nov 1999 to Mar 2004
  • Supervised a team of up to 27 team members.
  • Monitored incoming calls for quality control
  • Coached team on customer services as well as upselling.
  • Received several awards for team exceeding goals and production metrics.
Education and Training
HealthCare Administration University of Phoenix 2014 HealthCare Administration
References
Available Upon Request
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