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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)
This resume is created in 7 minutes.
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.
This resume is created in 7 minutes.
Professional Summary

Highly committed individual with proven ability to deliver excellent customer service and be a team player. Experienced in multiple office environments with demonstrated quick learning capabilities. Seeking to work with individuals in serving students in a higher education setting.  

Education
Bachelor of Science Public Health, Community and Behavioral Health East Tennessee State University Johnson City, TN | 2011
  • Minor in Psychology
Master of Science Higher Education in Administration Lee University Cleveland, TN | Expected July 2017
Skills
  • Strong Organizational Skills
  • Detail Oriented
  • MS Office Proficient

Excellent Comprehension and Retention

Fast Learner 

Interpersonal Skills


Work History
Belk Sales Associate | Cleveland, TN | November 2014 - Current
  • Provided a high level of service.
  • Meeting and exceeding units per transaction goals.
  • Settled a register and completed financial transactions accurately with no discrepancies.
  • Build productive trust relationships with customers by name.
  • Meeting Belk rewards program goals.
eviCore Claims Examiner II | Franklin, TN | March 2012 - Current
  • Numerical data entry.
  • Oversaw data entry function of claims submitted on HCFA 1500 and UB-92 forms.
  • Reviewed hospital and ancillary facility claims for accuracy and completeness of coding.
  • Processed claims for payment/denial.
  • Works claims inventory from assigned queues to ensure all claims process within established turnaround time as directed by department policy and procedures.
  • Identifies and review problems systematic or procedural with Supervisor for timely follow-up and correction.
  • Maintained organized files of paper claims.
  • Ability to multi-task and prioritize.
  • Consistently meet /exceed productivity standards and accuracy standards for payment, procedural and financial.
American Red Cross - Disaster Services Intern | Johnson City, TN | August 2011 - December 2011
  • Utilized CrossNet Intranet System for relief effort management.
  • Provided emergency relief to victims and refuges.
  • Assisted with clerical duties i.e., answering phones, copying, faxing, etc.
  • Created or updated databases.
  • Greeted guest or clients.
Records Office - East TN State University Federal Work Study | Johnson City, TN | May 2009 - August 2011
  • Managed the storage and availability of confidential information.
  • Maintained current knowledge of ETSU policy and procedures and referrals.
  • Utilized Banner Web systems to complete tasks.
  • Data entry for the purpose of preparing forms for further processing.
  • Attended community and campus events.
American Campus Communities Community Assistant | Johnson City, TN | May 2010 - January 2011
  • Provided star quality customer service.
  • Maintained conducive residential environment for academic and personal success.
  • Facilitated timely preparation of apartments for new resident.
  • Completed administrative task i.e., filing, calling, mailing, coping and faxing.
  • Sales and leasing.
  • Event planning.
This resume is created in 7 minutes.
Executive Summary
Results-focused high energy insurance management professional offering 20 years of progressive leadership experience in property, auto, BI & GL claims successful in building and motivating dynamic teams. Cultivates a company culture in which staff members feel comfortable voicing questions and concerns, as well as contributing new ideas that drive company growth.
Core Qualifications
  • Diverse Market/Industry Knowledge 
  • Extensive Leadership & Field Management
  • Multi-unit Operation Management
  • Staff Enrichment & Engagement
  • Training and Development
  • Quality Assurance
  • Commercial & Personal Lines Expertise
  • Budgeting & Expense Control
  • Vendor Management
  • Risk Management
  • CAT Experience
  • Excellent written, oral and interpersonal communication skills 
Professional Experience
SIU Team Leader, 05/2017 Current Gainsco Inc. Dallas, TX
  • Managed investigative staff  in AZ, NM, TX and OK
  • Successfully reduced fraud severity with an impact in 2016 of over $2,000,000.00 savings
  • Executed  SIU QA and said forms for audits and reviews
  • Directs strategic initiatives to standardize employee training for claims surrounding SIU partnership
  • Create financial plans covering projected growth areas based on PIF statistics
  • Defines strategy for of red flags, emerging trends, regulated reporting and vendor management
  • Dual responsibility for inside BI team and FNOL SIU coordinator
Account Executive, 08/2011 07/2012 CorVel Corporation
  • National book of business for workers compensation and liability clients securing multi-year renewals on existing accounts at renewal periods
  • Identified and secured expansion opportunities within the existing account base 
  • Facilitated and coordinated all claim reviews and stewardship meetings and implemented program changes including, but not limited to; procedural, location, staffing, and other program specific protocols
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Account Executive, 01/2010 07/2011 ACE/ESIS Irving, TX
  • Managed commercial accounts in excess of $3,000,000.00 establishing loss trends and means of improvement based on clients claim trending and needs.
  • Conducted pre-renewal and new business stewardships with a proactive approach to expanding business opportunities, consistently achieving business goals and retention.
  • Researched and resolved all client and broker needs to include claim reviews, renewal pricing, proposals, contracts and network and regulatory compliance. 
  • Communicated continually with clients and brokers in an effort to elevate said relationships further fostering positive outcomes.
Auto BI and General Liability Regional Manager, 05/2005 01/2010 Travelers Houston/Richardson, TX
  • Accountabilities for achieving established vision and developing and implementing strategies for both commercial and personal lines success
  • Coordinated talent identification thru all stages of interviewing and hiring to complete the growth and on boarding of the prospect to represent company and objectives
  • Analyzed statistics to identify emerging trends ultimately developing and implementing plans of action to elevate said performance of 15 - 20 team members with varying roles in two offices
  • Responded to and resolved Insurance Board inquiries along with customer complaints serving as an in-house resource for problem resolution
  • Built and lead teams successfully to become one of the highest performing groups with 90% of staff on succession planning career paths
  • Developed reporting and stretch goals exceeding expectations within region maintaining the top team/region in the company
  • Effectively developed budget and consistently remained within said financial goals
  • Chosen to be a part of the companies Leaders Developing Leaders Program.This program identified top talent by accelerating and providing broader opportunities and exposures for proven leaders ready to advance in expanded leadership roles - One of fifteen Individuals Company wide
  • Appointed as Claims Relationship Manager for elite agencies to foster and develop relationships acting as mediator on any problems that manifested as well as point of contact for business inquiries
  • Selected as company field facilitator and trainer in conjunction with specified proprietary educational programs
  • Led a project with senior leadership to improve the culture of the organization in the areas of communication, empowering, and listening to the professionals
  • Liaison to assigned Accounts to further establish the rapport and expertise needed to facilitate positive outcomes for all
  • Developed field marketing packet to enhance the client experience and efficiencies of the division which resulted in a companywide initiative
Regional HRP Manager, 02/2000 02/2004 American Family Insurance Schaumburg, IL
  • Handled design and coordination of company's home repair program throughout the Midwestern region for country's seventh largest insurer.
  • Developed and implemented program for claims offices which resulted in decreased expenditures, increased productivity and customer satisfaction and retention exceeding goals by 50%.
  • Marketed, recruited and negotiated contracts with contractors and restoration companies.
  • Instructed contractors, agents, and adjusters on program's features, procedures and benefits.
  • Developed job description and expectations for position adapted companywide and created various tools, forms and procedures for the programs growth.
Property Field Claims Examiner, 02/1997 02/2000 American Family Insurance Schuamburg, IL
  • Investigated and assessed damage to property and commercial losses using the Xactimate estimating system.
  • Gathered information from claimants, witnesses, and authorities to determine extent of damages and cause and origin.
  • Conducted new agent training monthly.
  • Effectively negotiated settlements that satisfied customers and limited costs.
Education & Affiliations
Stephen F Austin & Governors' State - Business and Criminal Justice Major
Extensive Insurance, Leadership and Claims training
Texas All Lines Adjuster License
Claims Litigation Management(CLM)
International Association of Special Investigators(IASIU)
National Insurance Crime Bureau (NICB)
Xactimate