A Claims Examiner will review insurance claims and verify the whole due process. A well-drafted Claims Examiner Resume indicate the following duties and tasks – ensuring legal compliance are met, approving or denying insurance claims, providing assistance to claims adjuster, determining if payouts are reasonable, meeting claimants and settling disputes, approving or rejecting claims, ensuring compliance with regulatory standards, providing assistance in managing huge volume of cases, consulting with lawyers, architects, and engineers; and assisting specialists when defending the company.
Some of the common requirements that an employer commonly looks forward include – hands-on experience and knowledge in claims processing, excellent ability to produce accurate work in a fast-paced environment and strong investigating skills. A Bachelor’s degree in relevant fields is commonly depicted on job resumes. However, many hirers want to see on the resume prior work experience in claims operations management.
Summary : Claims Examiner with a decade of expertise in evaluating and processing complex claims. Proficient in conducting thorough investigations and ensuring compliance with regulatory standards. Adept at training teams and enhancing operational efficiency, I strive to improve customer satisfaction through precise adjudication and effective communication. Passionate about delivering quality service while optimizing claims processes.
Skills : Analytical Problem Solver, Claims Cost Analysis, Effective Communication Skills, Claims Financial Management
Description :
Evaluated and adjudicated complex disability claims for individuals with physical and mental health conditions.
Coordinated with medical professionals to obtain and review essential medical documentation for accurate claim assessments.
Conducted thorough investigations in compliance with federal regulations, ensuring fair determinations on social security disability claims.
Processed approximately 1,500 claims annually, maintaining efficiency within a 50-day turnaround time.
Achieved a claims accuracy rate exceeding 98% through diligent analysis and validation.
Received multiple accolades for high-volume claims processing and exceptional claimant service based on positive feedback.
Presented educational materials on state and federal policies to enhance organizational knowledge and compliance.
Experience
7-10 Years
Level
Executive
Education
B.S. in Bus. Admin.
Claims Examiner-Customer Service Resume
Summary : With a solid decade of experience as a Claims Examiner, I excel in the meticulous evaluation and processing of diverse claims. My expertise includes conducting detailed investigations and ensuring adherence to regulatory requirements. Committed to optimizing claims processes, I foster team development and enhance customer satisfaction through clear communication and precise adjudication.
Skills : Customer Service Excellence, Results-driven Organization, Expert Problem Resolution, Regulatory Compliance, Problem Solving
Description :
Adjudicated life insurance, annuity, and group claims in compliance with state regulations.
Communicated with beneficiaries to inform them of claims status and benefits.
Reviewed legal documents such as wills and guardianship papers to assess claims validity.
Conducted detailed financial calculations and maintained compliance with state guidelines.
Developed training materials and conducted workshops for claims staff on best practices.
Ordered and analyzed medical records to support claims investigations.
Engaged with claimants and relevant parties to gather necessary information for claims analysis.
Experience
10+ Years
Level
Senior
Education
B.S. in BA
Claims Examiner II Resume
Summary : Dynamic Claims Examiner with over 10 years of experience in assessing and resolving intricate claims with precision. Skilled in conducting comprehensive investigations and ensuring compliance with industry regulations. Proven track record of enhancing claims processes, training staff, and boosting customer satisfaction through effective communication and meticulous adjudication.
Skills : Adaptability, Claims Analysis, Insurance Claims Management, Medicare And Medicaid Regulations, Data Management
Description :
Thoroughly examines and processes complex claims per business contract regulations and internal guidelines.
Accurately enters claims into the system after verifying coding for procedures and diagnosis.
Ensures compliance with established quality and production standards during claims processing.
Corrects processing errors through reprocessing, adjusting, and recouping claims.
Conducts research on claim issues using policies, reference materials, and coordination with internal support.
Responds to routine inquiries and prepares necessary documentation and reports.
Leads special projects, including reversing and processing claims as directed by legal departments.
Experience
10+ Years
Level
Senior
Education
B.S. in Bus. Admin.
Claims Examiner I Resume
Headline : Accomplished Claims Examiner with 7 years of experience specializing in the evaluation and resolution of complex claims. Expertise in conducting thorough investigations and ensuring compliance with regulatory standards. Committed to enhancing operational efficiency and customer satisfaction through effective communication and precise claims processing. Eager to leverage my skills to drive continuous improvement within claims management.
Skills : Claims Processing And Adjudication, Analytical And Problem-solving Skills, Team Development And Training, Legal Knowledge, Claim Denial Analysis, Regulatory Compliance
Description :
Acted as a technical resource for customer service inquiries, leveraging expertise to provide solutions.
Facilitated communication between management and customer service representatives regarding provider and member issues.
Resolved complex written and telephone inquiries escalated from upper management.
Conducted training sessions on claims processing and adjudication for new hires.
Provided professional and courteous responses to incoming inquiries from members and providers.
Addressed claims inquiries regarding benefits, policies, and procedures effectively.
Managed daily claims processing, ensuring accuracy in billing and adjustments.
Experience
5-7 Years
Level
Executive
Education
B.S. in BA
Sr. Claims Examiner Resume
Headline : Seasoned Claims Examiner with 7 years of specialized experience in evaluating and processing claims with precision. Expertise in conducting in-depth investigations while ensuring compliance with industry regulations. Strong communicator focused on enhancing operational efficiency and customer satisfaction through effective claims management and clear explanations of decisions.
Evaluated claim applications, physician statements, and policy records to ensure validity.
Coordinated with travel providers, physicians, and claimants to resolve complex coverage issues.
Reviewed adjustor reports to assess coverage and liability accurately.
Communicated with agents and claimants to rectify errors and clarify entries.
Managed incoming inquiries regarding coverage from claimants and customers.
Processed claim payments in accordance with settlement agreements and company policies.
Conducted thorough reviews of disputed claims using the established appeal process.
Experience
5-7 Years
Level
Executive
Education
B.S.B.A.
Senior Integrated Claims Examiner Resume
Headline : Detail-oriented Claims Examiner with over 5 years of experience in evaluating insurance claims, ensuring compliance with policies and regulations. Proven ability to analyze complex information, identify discrepancies, and make informed decisions. Strong communication skills facilitate effective collaboration with clients and stakeholders. Committed to delivering exceptional service and maintaining high standards of accuracy.
Evaluated employee, employer, and physician statements to determine approval or denial of short-term disability claims.
Conducted comprehensive phone interviews with claimants and medical professionals to gather necessary information for claims assessment.
Collaborated with in-house medical staff to validate medical documents against claims.
Reviewed special handling agreements to tailor the claims process for specific employee groups.
Requested and obtained medical and pharmacy records to support claim evaluations.
Interpreted company disability policies to ensure proper application to claims and clear communication with stakeholders.
Utilized reference materials to research and resolve discrepancies in claims effectively.
Experience
5-7 Years
Level
Executive
Education
B.S. in BA
Claims Examiner II Resume
Summary : Experienced Claims Examiner with 10 years in evaluating complex claims and ensuring compliance with industry regulations. Proven ability to streamline claims processing and enhance operational efficiency. Skilled in conducting in-depth investigations, fostering team collaboration, and improving customer satisfaction through effective communication and precise adjudication. Dedicated to maintaining high standards of accuracy in claims management.
Conduct comprehensive evaluations of claims to determine eligibility and benefit entitlement.
Gather and analyze information from claimants, employers, and relevant parties to resolve potential issues.
Utilize mainframe systems to compose and issue unbiased determinations in a timely manner.
Meet performance standards by making a high volume of accurate non-monetary determinations.
Assist in the resolution of claims appeals by providing detailed documentation and analysis.
Collaborate with team members to manage workload effectively and ensure timely claim processing.
Support case management for critically ill patients, facilitating direct negotiations for benefits.
Experience
7-10 Years
Level
Senior
Education
B.S. in BA
Insurance Claims Examiner V Resume
Summary : With 10 years of specialized experience as a Claims Examiner, I excel in the analysis and adjudication of complex claims. My expertise encompasses thorough investigations and strict adherence to regulatory standards. I am dedicated to enhancing operational efficiency and ensuring exceptional customer service through precise decision-making and effective communication.
Skills : Time Management, Regulatory Compliance Knowledge, Claims Process Optimization, Data Analysis Skills, Investigation Techniques
Description :
Evaluate and adjudicate 5-10 complex claims weekly, ensuring compliance with federal regulations.
Process compensation payments and determine eligibility for medical benefits based on current guidelines.
Refer cases to NIOSH for radiation dose reconstruction as per program protocols.
Collaborate with medical consultants for necessary claims determinations.
Provide sound recommendations based on EEOICPA regulations for assigned cases.
Maintain an accurate claims management system for effective case tracking.
Document claims payments and reserves, ensuring comprehensive file accuracy.
Experience
10+ Years
Level
Management
Education
B.S. in BA
Claims Examiner Customer Service Resume
Summary : Detail-oriented Claims Examiner with over 5 years of experience in evaluating insurance claims, ensuring compliance with policies and regulations. Proven track record in identifying fraudulent claims and implementing effective solutions. Strong analytical skills and proficiency in claims management software. Committed to delivering exceptional customer service while maintaining accuracy and efficiency in claims processing.
Skills : Quality Assurance, Case Management, Database Management, Research Skills, Documentation Skills
Description :
Reviewed and analyzed insurance claims for accuracy and compliance with policy guidelines.
Conducted investigations into claims involving potential fraud, ensuring compliance with company protocols.
Maintained regular communication with insureds, claimants, and attorneys to assess treatment status and claim progress.
Answered inquiries from insureds, claimants, and attorneys, providing clear and accurate information.
Reviewed police reports and secured statements to determine liability and fault in claims.
Negotiated settlements with insureds and claimants, achieving fair resolutions for all parties involved.
Managed a diverse caseload, including disability, life, and personal injury claims, ensuring timely processing.
Experience
10+ Years
Level
Senior
Education
B.S.B.A.
Claims Examiner Resume
Summary : Dedicated Claims Examiner with 10 years of extensive experience in analyzing and processing complex claims. My expertise encompasses rigorous investigations, regulatory compliance, and optimizing claims workflows. I am committed to enhancing customer satisfaction through precise adjudication and effective communication, ensuring a seamless claims experience for all stakeholders.
Skills : Attention To Detail, Customer Service, Data Entry, Customer Relations, Negotiation Skills
Description :
Executed comprehensive claims analysis and processed complex claims with accuracy and efficiency.
Conducted thorough investigations to determine claims validity, ensuring adherence to regulations.
Collaborated with policyholders and providers to gather necessary information for claims adjudication.
Reviewed and adjusted claims based on medical guidelines and corporate policies.
Managed litigated files, directing discovery and controlling litigation expenses.
Provided detailed exposure assessments and settlement recommendations, enhancing claims resolution.
Maintained high standards of accuracy while adjusting reserves and handling severe exposure claims.
Experience
7-10 Years
Level
Executive
Education
B.S.B.A.
Claim Examiner I Resume
Objective : Accomplished Claims Examiner with over 5 years of experience in evaluating and processing insurance claims. Proven ability to conduct thorough investigations, ensuring compliance with industry regulations. Committed to enhancing operational efficiency and customer satisfaction through effective communication and precise claims adjudication. Looking to leverage expertise to improve claims processes.
Conducted qualitative analysis of records to ensure accuracy and compliance with regulatory standards.
Addressed inquiries from providers, delivering detailed and accurate responses.
Accurately assigned descriptive codes based on multiple anatomical locations.
Processed claims efficiently to meet departmental deadlines and performance metrics.
Investigated coding discrepancies to ensure compliance and reimbursement accuracy.
Utilized coding books and online resources to support accurate claim processing.
Collaborated with healthcare professionals regarding billing policies and regulations.
Experience
2-5 Years
Level
Junior
Education
B.S. in HA
Claim Examiner Resume
Headline : Claims Examiner with 7 years of experience in efficiently evaluating and processing insurance claims. Skilled in conducting thorough investigations to ensure regulatory compliance and identifying opportunities for process improvement. Committed to enhancing customer satisfaction through clear communication and accurate adjudication, I aim to contribute to an organization's success in claims management.
Managed a diverse caseload of insurance claims, ensuring timely resolution.
Conducted detailed investigations to assess the validity of claims.
Identified claims requiring further analysis and initiated appropriate follow-up.
Recommended resolutions for claims based on thorough assessments.
Communicated with claimants to gather necessary information for claim processing.
Reviewed previously settled claims for accuracy and compliance.
Maintained detailed records for each assigned case to ensure transparency and accountability.
Experience
5-7 Years
Level
Executive
Education
B.S. in BA
Senior Claims Examiner II Resume
Objective : Results-oriented Claims Examiner with 2 years of specialized experience in processing and evaluating insurance claims. I excel in conducting comprehensive investigations and ensuring adherence to regulatory compliance. My focus on enhancing operational efficiency and delivering exceptional customer service drives successful claims outcomes.
Skills : Claims Management Software, Data Analysis and Reporting, Claims Processing, Attention to Detail, Analytical Skills
Description :
Managed a caseload of 200 claims, ensuring timely and accurate processing.
Conducted thorough investigations to assess claim validity and compliance with company policies.
Communicated effectively with clients, attorneys, and medical professionals to gather necessary documentation.
Provided exceptional customer service, resulting in positive feedback from clients.
Collaborated with cross-functional teams to enhance claims processing workflows.
Trained junior examiners on best practices and compliance standards.
Maintained detailed records of all claims activities and communications.
Experience
0-2 Years
Level
Executive
Education
B.S. in BA
Senior Claims Examiner Resume
Objective : Proficient Senior Claims Examiner with 5 years of experience in managing and resolving complex claims. Skilled in conducting thorough investigations and ensuring compliance with industry regulations. I focus on enhancing operational workflows and improving customer satisfaction through effective communication and precise adjudication. Eager to leverage my expertise to drive impactful changes in claims management.
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