Claim Examiner Resume Samples

Description :

1. Analyzed and managed complex or technically difficult claims by investigating and gathering information to determine the exposure on the claim.
2. Assessed the liability and resolves claims within an evaluation.
3. Negotiated settlement of claims within designated authority. Prepares necessary state fillings within statutory limits.
4. Calculated and assigned timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
5. Calculated and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level.
6. Managed the litigation process; ensures timely and cost-effective claims resolution.
7. Coordinated vendor referrals for additional investigation and/or litigation management.

Experience

7-10 Years

Level

Management

Education

Diploma

Description :

1. Worked as an Administrative Assistant, Claim Examiner, Temporary Claim Supervisor, Trainer and Hearing Representative.
2. Expertise was with Michigan Workers' Compensation claims.
3. Duties included claim management, making decisions on compensability, jurisdictional issues, and litigation plans of action, third party investigations.
4. Worked closely with the Michigan Second Injury Fund to obtain appropriate reimbursement.
5. Participated in completing technical details such as coding for the NCCI and reserving recommendations.
6. Participated in interviewing and hiring of additional staff in our Grand Rapids location while dedicated to the Steelcase account.
7. Assigned as the temporary supervisor during the regular supervisor's absence and trained and managed new employees.

Experience

10+ Years

Level

Senior

Education

Liberal Arts

Description :

1. Performed qualitative analysis of records to ensure accuracy, internal consistency and correlation of recorded data.
2. Researched questions and concerns from providers and provided detailed responses.
3. Accurately selected the proper descriptive code when more than one anatomical location was indicated.
4. Reviewed, analyzed and managed coding of diagnostic and treatment procedures contained in outpatient medical records.
5. Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
6. Resourcefully used various coding books, procedure manuals, and on-line encoders.
7. Interacted with providers and other medical professionals regarding billing and documentation policies, procedures and regulations.

Experience

2-5 Years

Level

Junior

Education

Information System

Description :

1. Responsible for managing a high volume workload concerning worker's compensation claims.
2. Responded to numerous emails and phone calls daily.
3. Able to multitask to accomplish the tasks of contacting employers, injured workers, and providers to facilitate the worker's compensation process.
4. Responsible to make initial contacts and complete the first investigation of each incoming claim.
5. Helped to quickly facilitate the direction of a claim and make the appropriate decisions to ultimately close the claim in a timely manner.
6. Claimed the examiner has utilized strong organizational skills, ability to multitask and valuable customer service skills.
7. Processed Commercial COB as well as many other different types of claims.

Experience

2-5 Years

Level

Junior

Education

BA

Description :

1. Interpreted policy provisions to determine eligibility and make claim determinations for Small Market, National, and Regional customers.
2. Initiated investigations through both company and external contacts to obtain medical and vocational evidence required for approval of a claim.
3. Established action plans for each file to bring a claim to resolution.
4. Evaluated claims to identify situations requiring referral to Senior Examiner.
5. Responded to written and/or telephone inquiries from policyholders, employers, and beneficiaries to resolve claim issues.
6. Actively pursued and followed up on open claims within specified timeframes.
7. Maintained production and quality standards.

Experience

7-10 Years

Level

Management

Education

Bachelor Of Science s

Description :

1. Processed claims timely and accurately in full accordance of Medicare-Medicaid guidelines, as well as guidelines set forth by the Health Plan.
2. Alerted management promptly of any identified issues that impact quality and production.
3. Met or exceeded quality and production standards set forth by management.
4. Identified and elevate potential Coordination of Benefits.
5. Monitored and followed up on pending claim activity timely and accurately.
6. Provided phone back-up for the Customer Service department as needed.
7. Assisted manager with reports and special projects as needed.

Experience

7-10 Years

Level

Management

Education

Diploma

Description :

1. Investigated, evaluated, negotiated, and settled claims, while exercising sound judgment.
2. Communicated effectively with all parties involved in a claim.
3. Developed and analyzed insurance contract data. Investigated coverage questions and claims.
4. Interpreted, evaluated, and prepared settlement estimates.
5. Successfully negotiated settlements with policyholders and claimants or their representatives.
6. Created and maintained a strong return to work program by assisting the insured's and claimants to develop realistic solutions.
7. Able to commute from home when work allowed.
   

Experience

5-7 Years

Level

Executive

Education

Occupational Education

Description :

1. Processed provider claims with a minimum of 97% procedural accuracy and 99% financial accuracy.
2. Maintained daily claims production standards. New Claim Entry, Keyed Claims and Copy Claims.
3. Maintained working knowledge of plan benefits designed.
4. Analyzed and authorized claim payment according to policies and provisions of the plan.
5. Reviewed and completed pended claims on a daily basis.
6. Entered and updated client/patient demographics and insurance information.
7. Completed miscellaneous tasks upon request/Support Service.

Experience

5-7 Years

Level

Executive

Education

Medical

Description :

1. Obtained and analyzed information to make claim decisions and payments on LTD, Voluntary disability and WOP claims.
2. Calculated and pays benefits due, and makes timely claim payments. Communicates with the facility and billing dept.
3. Responded to customer service issues within the required timeframes.
4. Referred claims above authority to a team lead/supervisor/manager.
5. Demonstrated the ability to independently handle claims.
6. Reported overpayments, underpayments, and other irregularities.
7. Trained on the coordination of benefits for MI and WA professional and facility claims.

Experience

5-7 Years

Level

Executive

Education

BBA

Description :

1. Conducted prompt and thorough investigations. Analyzed facts to identify any third-party liability.
2. Evaluated facts, laws, and damages to make liability decisions.
3. Reviewed estimates on property damage to determine the extent of the company's liability.
4. Analyzed facts and monitored activities in order to identify possible fraud or abuse.
5. Referred potential fraud or abuse claims to the proper fraud adjuster.
6. Wrote correspondence with medical providers, witnesses, policyholders, and attorneys.
7. First trained on processing guidelines for Medicare par and nonpar providers.

Experience

10+ Years

Level

Senior

Education

Diploma

Description :

1. A claims examiner manages a caseload of insurance claims.
2. Reviewed new claims to assess their validity. Investigate ability and availability for work.
3. Determined which claims require further investigation.
4. Recommended how each claim within her caseload should be resolved.
5. Examiner reached out to claimants to verify and complete his claim reports.
6. Reviewed previously paid claims for error or overpayment.
7. Investigated Keeps meticulous records of each of the cases assigned.

Experience

5-7 Years

Level

Executive

Education

Teaching