Utilization Management/Claims Representative Resume
Summary : Seeking to work for a fast-growing company that offers a promising career. I would also like the opportunity to provide quality service to achieve advancement through performance while learning new skills.
Skills : Microsoft Office, Microsft Outlook, Microsoft Excel, Typing, Answering Phones, Office Management, Customer Service, Billing, Claims Processing, Event Coordination, and Schedule Appointments.
- Contacts, interviews and obtains statements (recorded or in-person) from insureds, claimants, witnesses, physicians, attorneys, police officers, etc.
- Preparing reports on investigation, settlements, denials of claims, individual evaluation of involved parties etc.
- Setting reserves within authority limits and recommends reserve changes to team leader.
- Reviewing the progress and status of claims with team leader and discusses problems and suggested remedial actions.
- Preparing and submitting to team leader unusual or possible undesirable exposures.
- Assisting team leader in developing methods and improvements for handling claims.
- Obtaining releases, proofs of loss or compensation agreements and issues company drafts in payments for claims.
- Informing claimants, insureds/customers or attorney of denial of claim when applicable.
- Evaluating and negotiating with the injured person(s) while looking for early settlement opportunities.
Claims Representative I Resume
Objective : An energetic and versatile office and customer service professional with exceptional qualifications to deliver quality administrative and office support. Well-skilled at performing effectively independently and collaboratively as part of a team in fast-paced and demanding environments to complete assigned tasks and projects. Use excellent interpersonal and communication skills to build rapport and establish productive working relationships with customers and co-workers/peers.
Skills : Administrative Functions, Medical/Healthcare Terminology, Bilingual In English and Spanish, Maintain Focus, Detail Oriented, Computer/Software Applications.
- Maintain full responsibility for performing in a customer, administrative, and support role by providing quality and attentive service.
- Interact regularly with a diverse customer base including responding quickly to requests and resolving problems and issues in a timely and professional manner.
- Analyze claims to determine the extent of company's liability, make approval or denial decisions and negotiate settlements with claimants in accordance with policy provisions based on the extent of damages.
- Collaborate with insurance agents, rectify omissions and investigate questionable issues and makes referrals to the special investigations unit as appropriate.
- Refer claims to underwriting for review based on risk evaluation consistently contribute to improved efficiency, productivity, customer service, and company success.
- Established a reputation for professionalism and integrity and consistently deliver exceptional quality work.
- Investigate and assess damage to property and create or review property damage estimates.
- Negotiate claim settlements and recommend litigation when settlement cannot be negotiated.
- Interview or correspond with claimants, witnesses, police, and other relevant parties to determine claim settlement, denial, or review.
Claims Representative I Resume
Objective : An experienced professional looking for a challenging career opportunity, which would allow me to utilize my education, professional experience as well my interpersonal skills for the benefit of the organization.
Skills : Microsoft Office, Case Management, Documentation, Conflict Resolution, Typing, Report Preparation, Report Writing, Reporting, Interviewing, Investigations, Time Management, Analytical Thinking, Oral and Written Communication
- Adjusted compensable indemnity and medical special handling workers' compensation claims.
- Analyzed variables, such as job descriptions, weekly wages, and medical records and state required documentation.
- Calculated and assigns 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 clams within designated authority level.
- Coordinated vendor referrals for medical treatment, additional investigation and/or litigation management.
- Managed claim recoveries, including be not limited to subrogation, second injury fund excess recoveries, and social security and medicare offsets.
- Reported claims to the excess carrier; responds to requests of directions in a professional and timely manner.
- Communicating claim activity and processing with the claimant and the client; maintains professional client relationships.
- Work with accounting and collections staff to resolve carrier and customer accounting issues related to claims.
- Escalate claims to adjustment teams, rework processor's and subject matter experts follow standard operating procedures to process claims and payment information.
Senior Customer Claims Representative V Resume
Summary : Over 26 years of extensive experience as a Claims Representative. Seeking a long-term position that will utilize my experience and assist me with personal growth as well as advancement opportunities.
Skills : Close Attention To Detail, In Claim Investigations, Loss Prevention, Control Specialist, Cause and Origin Specialist, Legal Research, Microsoft Office, and Office Automation.
- Analyze information gathered by investigation, and report findings and recommendations.
- Interview or correspond with agents and claimants to correct errors or omissions and to investigate questionable claims.
- Review police reports, or physical property damage to determine the extent of liability.
- Negotiated settlements with all parties including claimant's attorney to ensure cost containment of the claims.
- Calculated and requested timely disability payments based on the information requested during the investigation of the claim.
- Coordinated referrals with vendors for additional investigation, litigation and the return to work of the injured worker corresponded with policyholders, claimants, agents, and others that are a party to the claim.
- Analyzed and processing workers' compensation claims by conducting detailed investigations, determining compensability, exposure, and benefits owed to the injured worker.
- Communicated and work side by side with many outside agencies such as nursing homes, police, group homes, pads, and lawyers to process claims.
- Handled all claim aspects of a file, including total losses, subrogation, and recoveries.
- Maintained an advanced understanding of the statute of limitations for every state, case law, and medical terminology.
Special Claims Representative Resume
Headline : Over 5 years of experience as a Claims Representative. In today's customer service oriented society, timely, friendly, proactive service is sought to enhance future business growth.
Skills : Knowledge Of CPT, HCPC, ICD-9, ICD-10 Codes, Knowledge Of HMO, PPO Medicare, and Medicaid, Microsoft Office, Excel, and Quick Books.
- Receive and process insurance information and forms from patients, insurance companies, and attorneys.
- Process additional information and request from patients, insurance companies, and attorneys on the billing of patient treatment.
- Review and manage patient accounts to ensure that proper documentation, payments, and necessary letters of authorization are entered correctly.
- Manage patient accounts through the company's database and coordinate with the home office in regards to medical information and billing to third parties.
- Proficiency in epic hospital system skills used the ability to evaluate pt transcripts and/or medical records.
- Performs various clerical duties under an immediate supervisor and exercises independent judgment and decision making in accordance with specified policies and guidelines.
- Maintains professionalism and confidentiality with regard to all aspects of claim property damage, injury and other personal information.
- Accurate and timely data entry in multiple Microsoft based applications.
Liability Claims Representative Resume
Headline : Seeking a position with growth and profitability of an organization that provides challenge encourages advancement, and rewards achievement with the opportunity to utilize my skills Summary of Qualifications & Skills. Adept to change in the work environment.
Skills : Microsoft Word, Powerpoint, Outlook, Excel, Java, Image right, Peoplesoft, Training & Development, Supervisory Experience, Quality Assurance, and Claims Processing.
- Handling incoming/outbound calls from external customers related to claim processing issues and the reporting of losses.
- Exercising the ability to multitask and communicate effectively while assisting customers via email or telephone.
- Reviewing the client's medical records to ensure that all conditions of care, operations, and procedures are properly documented.
- Reviewing medical records and consulted with medical providers to determine injuries are related to a motor vehicle accident.
- Referral to independent medical examiners (IME's) for further file handling of bodily injury claims.
- Reviewing property damage reports and photos to determine the extent of the company's liability and mechanism of injury in relation to motor vehicle damage.
- Educating providers through feedback, informal meetings and assisted in training new personnel assigned to the department.
- Successfully negotiated bodily injury settlements either by meeting face to face or via telephone.
- Authority to make decisions independently as well as, with a claims committee.
- Ensuring claim files are properly documented and claims coding is correct.
Claims Representative I Resume
Objective : One year of experience as a Claims Representative. Seeking to work for an organization where I can use my experience and skills in all aspects of the title insurance industry. I enjoy challenges and believe that given the chance I can contribute to the organization.
Skills : General Office Tools, Microsoft, and Employer Specific Software, Job Specific Applications, Legal Research, Microsoft Office, and Office Automation.
- Served on a dynamic team that processed all of the radiologic billing clams for CDI clinic locations in various states.
- Ensured that the correct coding was utilized to obtain optimum compensation for services rendered.
- Handled incoming calls from patient's concerning they are EOB (explanation of benefits) of which would generate a bill.
- End of month collection processing or referral was also mandatory, which would include outbound calls to patients in an attempt to collect payment to prevent the account being turned over to a collection agency.
- Recognized coverage issues, recommend liability positions and negotiated and settled property damage as well as bodily injury claims.
- Stayed knowledgeable in different state laws inclusive of medicare and Medicaid statutes.
- Recognizing potential fraudulent claims and moving them to the special investigative unit.
- Completed policy training and reference policy information for the handling and closure of a claim.
- Handled day to day inbound and outbound calls from customers and contractors.
Claims Representative/Call Center Resume
Summary : Over 14 years of experience as a Claims Representative. Work well in a high-pressure environment. Well-organized and efficient. Strong background in all phases of customer service. Skilled at encouraging others and developing rapport. Self-starting, goal-oriented strategist whose confidence, perseverance and vision promote success.
Skills : Office/Computer Support, Spreadsheets/Reports, Front-Desk Reception, Typing 60 Wpm, MS Office Suite, WordPerfect, Lotus, Working Knowledge With Windows XP, Vista, 7 and Mac.
- Investigate and evaluate auto and general liability claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases contributing to a reduced loss ratio.
- Contact and interview claimants, doctors, medical specialists, and employers for additional information to complete investigation.
- Adjust reserves and provide reserve recommendations to clients consistent with corporate policies.
- 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.
- Confer with legal counsel on claims requiring litigation successfully managed a pending of 120-140 at all times subrogate and arbitrate claims when applicable.
- Ensures claim files are properly documented and claims coding is correct.
- Tracking and tracing shipments to provide customer accurate information via emails and telephone.
- May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
- Manages workers compensation claims determining compensability and benefits due on long term indemnity claims monitors reserve accuracy, and files necessary documentation with the state agency.
- Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments.
Benefit Claims Representative Resume
Summary : Motivated professional with experience, knowledge, and education in human resources, organizational leadership/behavior, strategic management, and management functions. Communicates effectively on all levels. Identifies and seeks out opportunities to further improve knowledge and experience on an individual level as well as in a team dynamic. Strong organizational skills, project leadership, and problem-solving abilities. Proficient using Microsoft office suite. Always willing and ready to learn.
Skills : ESRI, Spatial Analytics, Critical Thinking, Team Player, Microsoft Office, Customer Relations, Call Center, Customer Retention, Supervising, and Training.
- Analyzing individual cases for the merit of reported changes, accuracy, completeness of documentation, and consistency of penalties according to policy.
- Providing technical assistance to co-workers on policy procedures and guidance on the appropriate courses of action to take that result from complex issues.
- Performing assignments and workload management designed to provide experience in the practical application of the principles, techniques, and concepts of the social security act.
- Clearly furnish oral or written advice, interpretation, and assistance to the general public and to stakeholders on various benefit issues.
- Utilizing specialized programs for completion of claims development, modification, referral, and list management.
- Maintaining critical attention to detail and good organizational skills to manage a high volume of claims.
- Acquiring the analytical ability necessary to analyze, interpret and evaluate relevant information essential in resolving low to moderate value, liability and bodily injury claims.
- Analyzing and managing claims by investigating and gathering information to determine the exposure on the claim; managed claims through a well-developed action plan to an appropriate and timely resolution, I was required to assess liability and resolve claims, negotiate settlement of claims within my designated authority.
- Directing activities of workers investigating claims to ascertain the validity of claims and extent of company liability.
- Investigating claims against transportation companies for shortages in or damaged freight, accidental death or injury to persons and private property damages.
Claims Representative Resume
Summary : Effective communicator with a comprehensive understanding of workers compensation. A solid background in outstanding customer service. Experience in Quality Improvement in connection with State Regulations.
Skills : Microsoft Office, Excel, Quick Books, IT/Telecom Experience, Network Media Asset Management, Multi-Screen/Application User, AV Setup, and Mac/PC Proficiency.
- Managing workers compensation claims determining compensability and benefits due to long term indemnity claims monitors reserve accuracy, and file necessary documentation with the state agency.
- Developing and managing workers compensation claims action plans to resolution, coordinates return-to-work efforts, and approves claim payments.
- Approving and processing assigned disability claims, determines benefits due, and manages action plan pursuant to the disability claim or client contract.
- Ensuring claim files are properly documented and claims coding is correct.
- Explaining rejected claims, manually submitting claims, fallow up with iht tool for CPT code errors.
- Handling and processing claims logged invoices for payment processing, reviewed proposal request from contractor's, trained new employees, managed reports on a daily basis.
- Investigating, evaluating, negotiating and settling the homeowner's claims in an assigned area to include verification of coverage and property damage, which requires one on one customer communication.
- Making sure that claims are genuine and no fraudulent activity has occurred.
- Investigating claims that have been submitted to the health plan due to physical or mental conditions.