Claim Examiner Resume
Summary : Innovative professional with years of progressive experience within hotel sales industry. Competent at managing responsibilities in fast-paced, high-volume atmosphere Schedule flexible.
Skills : Amisys 6.0, AWD, Power Step, MHC.
- Analyzed and managed complex or technically difficult claims by investigating and gathering information to determine the exposure on the claim.
- Assessed the liability and resolves claims within an evaluation.
- Negotiated settlement of claims within designated authority. Prepares necessary state fillings within statutory limits.
- Calculated and assigned timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
- Calculated and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level.
- Managed the litigation process; ensures timely and cost-effective claims resolution.
- Coordinated vendor referrals for additional investigation and/or litigation management.
Claim Examiner III Resume
Summary : To apply skills as a self-motivated, high-energy professional, with a rich functional and technical background in the insurance industry that allows to use those skills and experience to better the company.
Skills : Facet, Exp, Maces, MS-Excel.
- Worked as an Administrative Assistant, Claim Examiner, Temporary Claim Supervisor, Trainer and Hearing Representative.
- Expertise was with Michigan Workers' Compensation claims.
- Duties included claim management, making decisions on compensability, jurisdictional issues, and litigation plans of action, third party investigations.
- Worked closely with the Michigan Second Injury Fund to obtain appropriate reimbursement.
- Participated in completing technical details such as coding for the NCCI and reserving recommendations.
- Participated in interviewing and hiring of additional staff in our Grand Rapids location while dedicated to the Steelcase account.
- Assigned as the temporary supervisor during the regular supervisor's absence and trained and managed new employees.
Claim Examiner I Resume
Objective : Recent college graduate with information system knowledge. Professional, detail-oriented network administrator motivated to drive projects from start to finish as part of a dynamic team.
Skills : Microsoft Office, WordPoint.
- Performed qualitative analysis of records to ensure accuracy, internal consistency and correlation of recorded data.
- Researched questions and concerns from providers and provided detailed responses.
- Accurately selected the proper descriptive code when more than one anatomical location was indicated.
- Reviewed, analyzed and managed coding of diagnostic and treatment procedures contained in outpatient medical records.
- Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
- Resourcefully used various coding books, procedure manuals, and on-line encoders.
- Interacted with providers and other medical professionals regarding billing and documentation policies, procedures and regulations.
Jr. Claim Examiner Resume
Objective : To obtain a position within company utilizing 20 years of Health Insurance experience from processing Professional and Facility medical claims, or being a lead customer service representative.
Skills : Shorthand 10-Key, Terminology Coding, Type 60 Wpm.
- Responsible for managing a high volume workload concerning worker's compensation claims.
- Responded to numerous emails and phone calls daily.
- Able to multitask to accomplish the tasks of contacting employers, injured workers, and providers to facilitate the worker's compensation process.
- Responsible to make initial contacts and complete the first investigation of each incoming claim.
- Helped to quickly facilitate the direction of a claim and make the appropriate decisions to ultimately close the claim in a timely manner.
- Claimed the examiner has utilized strong organizational skills, ability to multitask and valuable customer service skills.
- Processed Commercial COB as well as many other different types of claims.
Claim Examiner/Co-ordinator Resume
Summary : Claim Analyst with nine years experience processing medical and hospital claims. Accurately investigate and resolve claim issues, processing payments or denials accordingly.
Skills : Bilingual- English and Spanish, Management.
- Interpreted policy provisions to determine eligibility and make claim determinations for Small Market, National, and Regional customers.
- Initiated investigations through both company and external contacts to obtain medical and vocational evidence required for approval of a claim.
- Established action plans for each file to bring a claim to resolution.
- Evaluated claims to identify situations requiring referral to Senior Examiner.
- Responded to written and/or telephone inquiries from policyholders, employers, and beneficiaries to resolve claim issues.
- Actively pursued and followed up on open claims within specified timeframes.
- Maintained production and quality standards.
Bachelor Of Science s
Claim Examiner/Representative Resume
Summary : Superior Health Service Professional and Administrative Assistant with a proven work ethic and ability to establish rapport with customers.
Skills : Technical Skills, MS-Excel.
- Processed claims timely and accurately in full accordance of Medicare-Medicaid guidelines, as well as guidelines set forth by the Health Plan.
- Alerted management promptly of any identified issues that impact quality and production.
- Met or exceeded quality and production standards set forth by management.
- Identified and elevate potential Coordination of Benefits.
- Monitored and followed up on pending claim activity timely and accurately.
- Provided phone back-up for the Customer Service department as needed.
- Assisted manager with reports and special projects as needed.
Claim Examiner II Resume
Headline : The competition for employment in today's world is astounding; however, a college degree in itself does not guarantee success in a position. Work experiences along with continuing higher education.
Skills : Communication Skills, MS-Office.
- Investigated, evaluated, negotiated, and settled claims, while exercising sound judgment.
- Communicated effectively with all parties involved in a claim.
- Developed and analyzed insurance contract data. Investigated coverage questions and claims.
- Interpreted, evaluated, and prepared settlement estimates.
- Successfully negotiated settlements with policyholders and claimants or their representatives.
- Created and maintained a strong return to work program by assisting the insured's and claimants to develop realistic solutions.
- Able to commute from home when work allowed.
Lead Claim Examiner Resume
Headline : Looking to obtain a Medical position with a stable Company with advancement opportuni- ties. Strongly motivated and ambitious idividual, personable as well as a teamplayer and leader.
Skills : Technical Skills, Management.
- Processed provider claims with a minimum of 97% procedural accuracy and 99% financial accuracy.
- Maintained daily claims production standards. New Claim Entry, Keyed Claims and Copy Claims.
- Maintained working knowledge of plan benefits designed.
- Analyzed and authorized claim payment according to policies and provisions of the plan.
- Reviewed and completed pended claims on a daily basis.
- Entered and updated client/patient demographics and insurance information.
- Completed miscellaneous tasks upon request/Support Service.
Associate Claim Examiner Resume
Headline : Innovative professional with six years of progressive experience within hotel sales industry. Competent at managing responsibilities in fast-paced, high-volume atmosphere Schedule flexible.
Skills : Technical Skills, Quick Learner.
- Obtained and analyzed information to make claim decisions and payments on LTD, Voluntary disability and WOP claims.
- Calculated and pays benefits due, and makes timely claim payments. Communicates with the facility and billing dept.
- Responded to customer service issues within the required timeframes.
- Referred claims above authority to a team lead/supervisor/manager.
- Demonstrated the ability to independently handle claims.
- Reported overpayments, underpayments, and other irregularities.
- Trained on the coordination of benefits for MI and WA professional and facility claims.
Asst. Claim Examiner Resume
Summary : Relevant work experience is in a claim environment working with injury claims including reviewing medical reports and bills. Experience in servicing existing accounts and reporting claims.
Skills : Computer, Word, Dictation Equipment, Office Equipment.
- Conducted prompt and thorough investigations. Analyzed facts to identify any third-party liability.
- Evaluated facts, laws, and damages to make liability decisions.
- Reviewed estimates on property damage to determine the extent of the company's liability.
- Analyzed facts and monitored activities in order to identify possible fraud or abuse.
- Referred potential fraud or abuse claims to the proper fraud adjuster.
- Wrote correspondence with medical providers, witnesses, policyholders, and attorneys.
- First trained on processing guidelines for Medicare par and nonpar providers.
Claim examiner Resume
Headline : Detail oriented Medical Billing/ Claims Examination with experience processing claims for various State Medicaid's, Medicare and replacement HMO's and 11 years customer service experience.
Skills : Bilingual- English And Spanish, Communication Skills.
- A claims examiner manages a caseload of insurance claims.
- Reviewed new claims to assess their validity. Investigate ability and availability for work.
- Determined which claims require further investigation.
- Recommended how each claim within her caseload should be resolved.
- Examiner reached out to claimants to verify and complete his claim reports.
- Reviewed previously paid claims for error or overpayment.
- Investigated Keeps meticulous records of each of the cases assigned.