Claims Examiner Resume Samples

Description :

1. Adjudicating disability claims for consumer's who are unable to work due to physical and mental disorders.
2. Request medical records from record department entities, while reviewing medical records with the intent of making determinations on applicant's medical eligibility for social security disability awarded benefits.
3. Under strict federal policies and procedure, I was responsible for accurately investigating and completed policy-based case analysis for medical doctors to determine whether a consumer meets social security disability requirements.
4. Yearly efficiently processed (within 50 days) for nearly 1,500 impaired or disabled individuals per year to assess medical limitations.
5. Achieved over 98% accuracy of claims based on the validation of medical decisions.
6. Earned multiple awards from management due to the high volume of claims filed and exemplary customer service based on positive feedback from claimants.
7. Successfully completed public speaking and powerpoint presentations for organizational continuance education on state and federal program policies and procedures.
8. Maintained professional relations with dark agencies senior level leadership.
9. Works under a limited supervisor and considerable latitude for the use of initiative and independent judgment.
10. Oversees the development and administration of the disability determination or workers' compensation program.

Experience

7-10 Years

Level

Executive

Education

MBA

Description :

1. Responsible for paying life insurance, annuity, and group claims in accordance with state guidelines.
2. Locate and contact family members of deceased policyholders to inform them of benefits payable to beneficiaries.
3. Interpret last will and testaments, estate/guardianship documents and divorce decrees.
4. Performed financial calculations for interest and created spreadsheets for calculations to ensure the business remained compliant with state-specific guidelines.
5. Investigated claims involving potential and suspected fraudulent activities.
6. Trained other claims staff members on proper handling and evaluation of claims.
7. Ordered and reviewed medical records from medical facilities and pharmacies.
8. Contact and/or interview claimants, next of kin, doctors, medical specialists, employers and police to get additional information for claim investigation.
9. Documented all investigation activity for contestable claims and presented reports to management.
10. Report and recover overpayments, underpayments, and other irregularities.

Experience

10+ Years

Level

Senior

Education

PA

Description :

1. Responsibilities 70% examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines.
2. Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes.
3. Ensures that claims are processing according to established quality and production standards.
4. Corrects processing errors by reprocessing, adjusting, and/or recouping claims.
5. Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas.
6. Responds to routine correspondence and completes spreadsheets if applicable.
7. Special projects- reversing and redoing multiple claims as ordered from presidential and legal departments.
8. Organized forms, made photocopies, filed records, and prepare correspondence and reports.

Experience

10+ Years

Level

Senior

Education

Diploma

Description :

1. Responsible for acting as a technical resource due to my level of expertise in the customer service area.
2. Liaisoning between management and the customer service representative by fielding questions regarding providers/member issues.
3. Resolving difficult written and telephone inquiries for upper management.
4. Training to process and pay claims and trained others on how to understand the process of paying claims.
5. Answering incoming questions from members, as well as, providers in a professional and courteous manner.
6. Resolving inquiries from provider and members' claims regarding benefits, policies, and procedures.
7. In addition, responsible for daily claims processing and billing concerns.
8. Adjusting claims and billing errors, as well as, sent claims to processing for review and advised members and providers of processing updates.
9. Accomplishments graduated from a class of 23 representatives in the top 5 with an overall grade of 94%.
10. Responding to questions from customer service representatives regarding a claim.

Experience

5-7 Years

Level

Executive

Education

Diploma

Description :

1. Comparing data on claim applications, physician statements, or death certificates with policy file and other company records to ascertain completeness and validity of the claim.
2. Contacting travel providers, physicians, claimants, or others involved resolving coverage questions.
3. Examining claim adjustor reports or similar claim/precedents to determine the extent of coverage and liability.
4. Corresponding with agents and claimants to complete or correct errors or omissions on claim forms and to investigate or clarify questionable entries.
5. Handling incoming calls regarding coverage to claimants, customers, and prospects.
6. Paying claimants amounts due according to settlement agreements and company procedures.
7. Reviewing and determining disputed claims using the approved company claims appeal process.
8. Preparing clear and appropriate explanations of claims denied citing exact reasons for the denial.
9. Communicating with other insurance companies, for coordination of benefits or subrogation purposes.
10. Reviewing new claims to assess their validity, determine if further investigation is necessary.

Experience

5-7 Years

Level

Executive

Education

BBM

Description :

1. Reviewing employee, employer, and attending physician statements to determine if a short term disability claim should be approved or denied.
2. Conducting phone interviews of claimants, employers, physicians, and nurses to gather as much information as possible in order to supplement the information included in claim documents.
3. Meeting with in house medical staff to review medical documents and decide if disabilities are supported by available medical information.
4. Reviewing special handling agreements in order to provide personalized experiences for certain employee groups.
5. Faxing requests for medical records, pharmacy records, and other types of information to supplement claim information.
6. Reviewing company disability policies in order to effectively apply policy language to claims and to be able to communicate policy language correctly to employees and employment groups.
7. Utilizing appropriate reference materials to research information, respond to resolve problems.
8. Preparing and/or initiates a variety of correspondence and documents to respond to inquiries/problems.
9. Conducting fact-finding telephone interviews to resolve discrepancies with claims.
10. Satisfactory completion of licensing certification courses and passed the state exam.

Experience

5-7 Years

Level

Executive

Education

GED

Description :

1. Identifying potential issues that can affect an individual's entitlement to benefits.
2. Gathering facts from claimants, employers, and other pertinent or interested parties relating to potential issues and the charge ability of employer accounts for benefit payments on claims.
3. Composes and issues written, unbiased determinations through interaction with the non-monetary determinations mainframe computer program.
4. Making an adequate quantity of non-monetary determinations in compliance with performance standards.
5. Issues are written and unbiased determinations relating to the charge ability of employer tax accounts for benefit payments pursuant to the requirements.
6. Assisting other examiners as needed due to workload requirements including back-up when examiners are absent.
7. Assisting the team leader and/or claims manager in the resolution of claims appeals and disputes by providing documentation for review.
8. Assigning critically ill patients to large case management and assists the case manager with direct negotiation and the efficient use of benefits.

Experience

7-10 Years

Level

Senior

Education

BBM

Description :

1. Adjudicates five to ten claims a week for occupational illnesses based on exposure to radiation, covered illnesses based on exposure to toxic substances and survivor claims totaling from $125, 000 to $400,000.
2. Processing compensation payments and determines payments of compensation for medical benefits according to current federal regulations.
3. Making referrals to the national institute of occupational safety and health (NIOSH) for radiation dose reconstruction based on program procedures.
4. Making referrals to the district medical consultant for medical determinations necessary for the processing of claims.
5. Processing sound and justifiable recommendations based on the regulations of the energy employees occupational illness compensation program act (EEOICPA) when needed on cases assigned based on the applicable law, rules, and regulations.
6. Maintaining the claims management system to ensure proper tracking of cases.
7. Entering claim payments, reserves and new claims on the computer system, inputting concise yet sufficient file documentation.
8. Determining covered medical insurance losses by studying provisions of policy or certificate.
9. Maintaining quality customer services by following customer service practices; responding to customer inquiries.
10. Ensuring legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.

Experience

10+ Years

Level

Management

Education

MBA

Description :

1. Evaluated insurance policies and analyzed damages to determine coverage.
2. Investigated claims involving potential and suspected fraudulent activities.
3. Maintained contact with insured(s), claimant(s) and/or attorney(s) to determine treatment status.
4. Answered questions proposed by insured(s), claimant(s) and/or attorney(s).
5. Reviewed police reports, secured statements, reviewed vehicle and property damage to determine negligence for liability/fault.
6. Discussed settlement evaluations with insured(s), claimant(s) and/or attorney(s) and negotiate and settle injury claim(s).
7. Broad claims caseload includes disability, life, involuntary unemployment, and a personal milestone.
8. Responsible for examining healthcare claims for incidences of fraud and timely filing.
9. Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.
10. Prepares reports by collecting, analyzing, and summarizing information.

Experience

10+ Years

Level

Senior

Education

Diploma

Description :

1. Manually calculating benefits determination (non-payable categories, savings, and payments) and/or re-enters claims using the PAC (pre-adjudication correction) process for original and re-opened claims to be adjusted.
2. Medical guidelines, corporate policy, contract provisions, other coverage, etc. ) to determine the appropriate course of action.
3. Subscribers, providers, brokers and/or policyholders) during the course of a review to clarify and/or gather additional information required to process claims.
4. Updates/manually processes/adjust claims and/or records as appropriate.
5. Managing and controlled all litigated files directing discovery and managed litigation and loss assessment expenses.
6. Providing exposure assessments and settlement recommendations to carriers accomplishments earned performance-based bonuses for exceptional claims handling skills used demonstrated ability to perform at a high level exceeding client expectations in loss exposure assessment.
7. Responsibilities provide TPA claims handling for national and international insurers.
8. Examining claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
9. Adjusting reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies resolve complex, severe exposure claims, using high service oriented file handling.
10. Investigating, evaluating, and settling claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio.

Experience

7-10 Years

Level

Executive

Education

GED