A Claims Specialist job role includes examining claims, negotiating and processing settlements, verifying insurance coverage and reviewing insurance cases. Job duties listed on a Claims SpecialistResume include some or all of these – reviewing insurance claims, assisting insurance adjuster with unusual or complicated claims, performing detailed site inspections, reviewing and processing new claims reports or court verdicts; negotiating settlements, resolving claims in a timely manner, determining the validity of the claim, compiling reports and staying up-to-date with state and federal laws.
Even though the job description may vary with the type of insurance, the needed skills are common and include – the ability to treat all clients fairly and equitably; being legitimate and reasonable, knowledge of claims verification, and payment processing; and the potential to deal with customers in a diplomatic manner. For an entry-level position, high school or GED will help. A combination of experience and education may be considered in lieu of a degree.
Objective : Dynamic Claims Specialist with 2 years of experience in managing and resolving insurance claims efficiently. Skilled in investigating claims, coordinating with clients and attorneys, and ensuring compliance with policies. Committed to delivering exceptional service and optimizing processes to enhance customer satisfaction and operational success.
Reviewed and processed insurance claims to ensure accuracy and compliance with company policies.
Resolved accounts efficiently by communicating with patients, attorneys, and adjusters.
Reviewed and researched accident claims to identify potential leads and gather necessary information.
Communicated with clients to gather necessary information for claim processing and resolution.
Requested documentation from insurance representatives for claims without no-fault insurance.
Closed and returned claims to clients upon resolution, adhering to denial process protocols.
Utilized MRA039's case management system, Acclaim, for accurate account documentation.
Experience
0-2 Years
Level
Entry Level
Education
B.S.B.A.
Junior Claims Specialist Resume
Objective : Proactive Junior Claims Specialist with 2 years of experience in efficiently processing and resolving insurance claims. Proficient in claim investigations, client communication, and adherence to industry regulations. Eager to enhance operational processes and deliver outstanding customer service while supporting team objectives.
Investigated claims related to theft, fire, and complex liability issues, ensuring accurate assessments.
Mentored new employees on claims resolution and policy compliance.
Reviewed and corrected ISO Claim Errors, improving team performance metrics.
Facilitated liability meetings to address and resolve disputes effectively.
Cross-trained in call center operations to support customer inquiries.
Consistently received top performance reviews, ranking in the top 10% of employees company-wide.
Implemented process improvements that enhanced operational efficiency.
Experience
0-2 Years
Level
Junior
Education
B.S. in BA
Claims Specialist Resume
Headline : Seasoned Claims Specialist with 7 years of expertise in effectively managing insurance claims processing and resolution. Demonstrated proficiency in analyzing complex claims, ensuring regulatory compliance, and delivering exceptional customer support. Driven to enhance operational efficiency and foster strong client relationships while maintaining high standards of accuracy and service.
Skills : Research Skills, Claims Adjustment, Financial Acumen, Quality Assurance, Process Improvement, Client Relations
Description :
Managed disability, medical, and death claims processing, ensuring compliance with health insurance regulations.
Analyzed claims to assess company liability and made informed approval or denial decisions.
Conducted thorough investigations, ensuring timely and accurate claim resolutions.
Gathered necessary documentation to evaluate claims and determine additional information needs.
Provided exceptional customer service, addressing inquiries and resolving issues for members and providers.
Processed policy changes for individual health plans, maintaining accuracy and compliance.
Oversaw health insurance compliance reporting and responded to inquiries from State Insurance Departments.
Experience
5-7 Years
Level
Senior
Education
B.S.B.A.
Associate Claims Specialist Resume
Objective : Detail-oriented Associate Claims Specialist with 2 years of experience in processing and resolving insurance claims. Adept at client communication, claims investigation, and regulatory compliance. Passionate about enhancing operational efficiency and delivering high-quality service to clients while supporting team goals.
Skills : Problem Solving, Time Management, Data Analysis, Documentation Review, Policy Knowledge, Conflict Resolution
Description :
Collected and analyzed customer feedback to implement process improvements, exceeding satisfaction goals.
Adapted procedures to accommodate unique customer requests while maintaining compliance.
Demonstrated mastery of claims processing protocols within established timeframes.
Addressed and resolved customer inquiries promptly, ensuring accurate information delivery.
Maintained comprehensive records, fostering effective communication across departments.
Collaborated with management to drive initiatives aimed at enhancing customer satisfaction.
Followed up with customers post-resolution to ensure loyalty and address any ongoing concerns.
Experience
0-2 Years
Level
Entry Level
Education
B.S.B.A.
Claims Specialist Resume
Summary : Accomplished Claims Specialist with a decade of experience in effectively managing insurance claims and optimizing resolution processes. Expertise in analyzing complex claims, enhancing compliance, and delivering exceptional client service. Proven ability to streamline operations and foster teamwork, resulting in increased customer satisfaction and operational efficiency.
Collaborated with legal counsel on high-stakes claims requiring litigation to ensure precise representation.
Presented detailed case analyses at claim committee meetings, contributing to informed decision-making.
Developed and implemented strategies to improve claims processing efficiency, resulting in faster resolution times.
Monitored compliance with state and federal regulations to mitigate risk and ensure adherence to industry standards.
Conducted thorough investigations to substantiate claims and identify fraudulent activity.
Created comprehensive reports on claims trends and outcomes for upper management review.
Maintained strong relationships with clients and stakeholders to enhance service delivery and satisfaction.
Experience
7-10 Years
Level
Management
Education
B.S. in BA
Disability Claims Specialist Resume
Headline : With seven years of experience as a Disability Claims Specialist, I excel in evaluating and processing claims while ensuring adherence to regulatory standards. My expertise in client communication and investigative analysis drives efficient claims resolution. I am dedicated to enhancing operational workflows and delivering exceptional support to claimants, fostering a positive claims experience.
Skills : Claims Evaluation, Legal Knowledge, Workflow Management, Training And Mentoring
Description :
Evaluated and processed disability claims, ensuring compliance with legal and regulatory standards.
Communicated with claimants, medical professionals, and legal representatives to gather necessary information.
Analyzed complex claims and determined eligibility based on policy guidelines.
Documented findings and decisions in a clear and organized manner for audit purposes.
Identified potential fraud cases and escalated to the appropriate department for further investigation.
Worked collaboratively with cross-functional teams to enhance claims processing efficiency.
Provided exceptional customer service to claimants, addressing inquiries and concerns promptly.
Experience
5-7 Years
Level
Senior
Education
B.S. in Bus. Admin.
Claims Specialist Resume
Objective : Dedicated Claims Specialist with 2 years of hands-on experience in processing and resolving insurance claims. Proficient in investigating claims, liaising with clients, and ensuring adherence to regulatory standards. Focused on delivering exceptional service and improving operational workflows to enhance client satisfaction and efficiency.
Managed and processed insurance claims, ensuring accuracy and compliance with policies.
Responded to client inquiries regarding claim status and coverage details.
Coordinated with medical providers for necessary documentation related to claims.
Scheduled independent medical examinations for claimants as needed.
Maintained organized records of claims and correspondence for easy reference.
Handled non-complex claims such as glass and towing efficiently.
Guided clients to appropriate departments for further assistance.
Experience
0-2 Years
Level
Entry Level
Education
B.S. in BA
Billing Claims Specialist Resume
Objective : Enthusiastic Billing Claims Specialist with 2 years of hands-on experience in managing and resolving diverse insurance claims. Proficient in conducting thorough investigations, collaborating with clients and healthcare providers, and ensuring compliance with industry regulations. Focused on delivering high-quality service and streamlining processes to enhance operational efficiency and customer satisfaction.
Skills : Microsoft Office Suite, Database Management, Claim Settlement, Insurance Terminology, Statistical Analysis, Case Management
Description :
Processed over 500 insurance claims, ensuring compliance with policies and regulations.
Provided exceptional service to policyholders, negotiating fair settlements and identifying potential fraud.
Served as the primary contact for complex claims, facilitating timely resolutions.
Participated in quality audits to ensure adherence to claims procedures.
Monitored updates on claims status, providing accurate information to clients.
Communicated warranty processes clearly to customers, enhancing their understanding.
Outlined necessary documentation for warranty claims and financial processing.
Experience
0-2 Years
Level
Junior
Education
AAS
Claims Specialist Resume
Summary : Accomplished Claims Specialist with over 10 years of experience in managing complex insurance claims. Expertise in investigation, resolution, and compliance, ensuring fair outcomes for all parties. Adept at enhancing operational processes and fostering strong client relationships, I am dedicated to delivering exceptional service and achieving organizational goals.
Investigated and assessed claims, utilizing technical expertise to ensure fair and prompt resolutions, contributing to a significant reduction in loss ratios.
Supervised and trained claims adjusters, ensuring adherence to best practices and enhancing overall team performance.
Resolved complex claims efficiently, applying a customer-centric approach to enhance satisfaction.
Processed and authorized claims within established authority levels, maintaining compliance with company policies.
Conducted thorough examinations of claims, collaborating with adjusters to investigate and validate questionable claims before payment authorization.
Verified and analyzed claims data to ensure accuracy and compliance with industry standards.
Developed and implemented strategies to optimize claims management processes, resulting in improved operational efficiency.
Experience
10+ Years
Level
Executive
Education
B.S. in BA
Senior Claims Specialist Resume
Summary : Accomplished Senior Claims Specialist with a decade of extensive experience in managing complex insurance claims and enhancing operational efficiencies. Expert in conducting thorough investigations, ensuring regulatory compliance, and delivering outstanding client service. Passionate about driving process improvements and fostering strong relationships to optimize claims resolution and exceed organizational objectives.
Skills : Sales Skills, Product Knowledge, Training Skills, Work Ethic
Description :
Adjusted reserves and provided recommendations to align with corporate policies, enhancing financial accuracy.
Collaborated with third-party providers to ensure timely and effective resolution of claims.
Uncovered fraudulent claims schemes, leading to significant recovery of insurance overpayments.
Researched and ensured compliance with environmental guidelines and processing laws at state and federal levels.
Reviewed and processed medical bills, ensuring accurate application of policyholder coverages.
Formulated and enforced quality assurance measures, enhancing service center operations.
Utilized advanced Excel skills to consolidate Access database reports for monthly corporate audits.
Experience
7-10 Years
Level
Management
Education
B.S. in BA
Claims Specialist Resume
Headline : Accomplished Claims Specialist with 7 years of extensive experience in managing insurance claims, ensuring compliance, and driving efficient resolution processes. Expertise in analyzing complex claims and fostering positive client relationships. Committed to enhancing operational workflows and delivering exceptional service, consistently exceeding organizational objectives.
Skills : Documentation Skills, Record Keeping, Claims Review, Time Tracking, Claim Denial Management
Description :
Managed the processing of claims filed through various channels, ensuring timely resolution.
Conducted thorough investigations of liability claims, analyzing evidence to determine validity.
Communicated effectively with clients and claimants to resolve inquiries and provide updates.
Provided guidance on claims coverage and resolved disputes for pending claims.
Handled subrogation processes and prepared claims for arbitration, ensuring compliance with regulations.
Coordinated vehicle inspections, facilitating appointments between clients and repair facilities.
Evaluated medical claims for accuracy and issued payments to providers for valid claims.
Experience
5-7 Years
Level
Senior
Education
B.A. in BA
Associate Claims Specialist Resume
Objective : Insurance claims professional with 2 years of experience in efficiently assessing and resolving claims. Expertise in conducting thorough investigations, collaborating with clients, and ensuring compliance with policy regulations. Passionate about enhancing customer support and streamlining processes to achieve optimal operational outcomes.
Skills : Customer Retention, Data Analysis Tools, Insurance Underwriting, Problem Resolution, Client Correspondence, Policy Analysis
Description :
Assessed coverage and limits based on policy language for reported losses.
Communicated reasons for claim denials clearly to clients, enhancing understanding.
Conducted detailed inquiries to identify potential fraud in claims.
Determined item values based on current market assessments.
Negotiated replacement costs and explained depreciation to clients.
Supported team members during peak claim volumes, improving overall efficiency.
Received high satisfaction ratings from clients for claims handling.
Experience
0-2 Years
Level
Entry Level
Education
B.S. in BA
Claims Specialist Resume
Objective : Claims Specialist with 2 years of experience in efficiently processing and resolving insurance claims. Expertise in conducting thorough investigations, maintaining compliance, and enhancing client relations. Dedicated to delivering high-quality service and streamlining operational processes to ensure optimal outcomes for clients and the organization.
Evaluated claims for coverage and determined appropriate payouts based on policy terms.
Reviewed supporting claims documents, ensuring accuracy and compliance.
Rejected incomplete documents and communicated with senders for missing information.
Participated in educational opportunities to enhance job knowledge and skills.
Established and maintained personal networks to support claims processes.
Verified members' benefit plans to ensure coverage compliance.
Compiled proof of loss by analyzing medical documentation and other relevant information.
Experience
0-2 Years
Level
Junior
Education
B.S.B.A.
Claim Specialist Resume
Objective : Claims Specialist with 2 years of experience in efficiently processing and resolving insurance claims. Adept at conducting thorough investigations, communicating with clients, and ensuring compliance with industry regulations. Passionate about optimizing processes to enhance customer satisfaction and drive operational efficiency.
Participated in team meetings to discuss claims trends and share best practices.
Assisted in the development of training materials for claims staff.
Maintained up-to-date knowledge of industry regulations and changes in insurance laws.
Responded to inquiries from clients and agents regarding claim status and procedures.
Coordinated with legal teams on claims involving litigation or disputes.
Adapted to changes in regulations for deductibles and collections.
Identified opportunities for cost savings through effective claims management.
Experience
0-2 Years
Level
Junior
Education
B.S. in BA
Assistant Claims Resolution Specialist Resume
Objective : Results-oriented professional with 2 years of experience in claims resolution and customer service within the insurance sector. Proven ability to investigate claims thoroughly, communicate effectively with stakeholders, and ensure compliance with regulatory standards. Dedicated to improving operational processes and providing exceptional support to clients throughout the claims lifecycle.
Managed claims processing for CIGNA, ensuring maximum discounts and reimbursement retention.
Identified and implemented process enhancements to improve service quality and efficiency.
Communicated effectively with providers, stakeholders, and clients to resolve claims issues.
Processed mental health claims, ensuring accuracy and compliance.
Trained colleagues on claims processing protocols and procedures.
Volunteered to handle complex accounts, demonstrating initiative and problem-solving skills.
Assisted clients in rectifying discrepancies in claims processing.
Experience
0-2 Years
Level
Entry Level
Education
B.S. in BA
Claims Resolution Specialist Resume
Objective : Motivated Claims Resolution Specialist with 2 years of experience in effectively addressing and resolving insurance claims. Proven ability to conduct detailed investigations, collaborate with clients and insurers, and ensure compliance with industry standards. Dedicated to enhancing customer satisfaction through efficient service and streamlined processes.
Established effective monthly payment plans for patients unable to settle their balances in full.
Monitored patient credit balances for refunds and coordinated with the Billing Manager for approval.
Processed and mailed refund checks, accurately documenting transactions in patient accounts.
Delivered exceptional customer service by promptly providing accurate billing information.
Prioritized daily billing operations to address customer needs with timely resolutions.
Identified and resolved billing issues through thorough research and analysis.
Reviewed, corrected, and appealed unpaid and denied claims, ensuring compliance with submission guidelines.
Experience
0-2 Years
Level
Junior
Education
B.S.B.A.
Claims Service Specialist III Resume
Headline : Results-focused Claims Service Specialist with 7 years of experience in managing and resolving complex insurance claims. Adept at analyzing claims, ensuring compliance with regulatory standards, and delivering exceptional client service. Committed to optimizing processes and enhancing operational efficiency to drive customer satisfaction and improve outcomes.
Conducted thorough investigations of claims, applying analytical skills to ensure accurate and fair resolutions.
Entered and maintained claims data in the system, ensuring comprehensive documentation and adherence to protocols.
Managed case files, including records of settled claims and those requiring further analysis.
Identified and reported overpayments, ensuring financial integrity in claims processing.
Reviewed policies to determine coverage and eligibility for claims.
Utilized analytical skills to assess risk and make informed claims decisions.
Provided assistance to clients in navigating the claims process, enhancing their experience and understanding.
Experience
5-7 Years
Level
Senior
Education
B.S. in BA
Claims Service Specialist Resume
Objective : Dedicated Claims Service Specialist with 2 years of experience in efficiently handling and resolving insurance claims. Adept at conducting thorough investigations, ensuring compliance, and providing exceptional customer support. Passionate about enhancing operational processes and delivering high-quality service to improve client satisfaction.
Investigated and analyzed claims against auto insurance, providing recommendations based on findings.
Established courteous relationships with clients and colleagues to facilitate smooth claims processing.
Verified coverage for first and third-party auto claims while ensuring accuracy and preventing fraud.
Performed essential administrative tasks including data entry, filing, and record-keeping.
Reviewed appeals from providers to ensure claims were processed accurately and fairly.
Applied adjustments to claims based on thorough research of plan details.
Assessed claims to determine legitimacy, ensuring compliance with industry standards.
Experience
0-2 Years
Level
Entry Level
Education
B.S.B.A.
Senior Claims Specialist II Resume
Headline : With seven years of comprehensive experience in claims management, I excel in processing complex insurance claims and ensuring regulatory compliance. My expertise in client relations and investigative analysis drives efficient resolutions, fostering strong partnerships. I am dedicated to optimizing workflows and delivering exceptional service, consistently exceeding expectations in claims processing.
Created and maintained a claims database for tracking and reporting purposes.
Managed coverages including professional liability and general liability, applying them to multi-district jurisdictions.
Drafted indemnity agreements for self-insured retention accounts.
Determined insurance and reinsurance coverages through extensive analysis.
Developed and implemented organizational policies to enhance operational efficiency.
Supervised Home Office staff across multiple regional offices, ensuring effective communication and workflow.
Directed and managed a substantial caseload, maintaining high standards of accuracy and compliance.
Experience
5-7 Years
Level
Senior
Education
B.S.B.A.
Lead Senior Claims Specialist Resume
Summary : Accomplished Lead Senior Claims Specialist with over 10 years of expertise in managing complex insurance claims and driving process improvements. Proven ability to conduct thorough investigations, ensure compliance, and deliver exceptional client service. Committed to optimizing operational workflows and fostering strong relationships to achieve organizational objectives and enhance customer satisfaction.
Skills : Service Orientation, Claims Investigation And Analysis, Insurance Policies, Legal Compliance, Insurance Adjusting
Description :
Analyzed claim data to identify trends and potential fraud indicators.
Managed timely and accurate filing of investor claims, including follow-ups and fund reconciliations.
Ensured servicing documents were submitted to carriers promptly to prevent delays in claims processing.
Conducted detailed analyses for month-end reporting, highlighting key performance metrics.
Reviewed contracts and evaluated information from documentation to inform claims decisions.
Interacted with plaintiff attorneys, discussing legal concepts to facilitate effective claims resolution.
Recommended claims strategies to set aside appropriate reserves and settle cases efficiently.
Experience
7-10 Years
Level
Management
Education
B.S.B.A.
Senior Claims Specialist Resume
Headline : Detail-oriented Claims Specialist with over 5 years of experience in processing and managing insurance claims. Proven track record of resolving complex claims efficiently while ensuring compliance with company policies and regulations. Strong analytical skills and ability to communicate effectively with clients and stakeholders to facilitate smooth claims resolution.
Managed catastrophic injury claims, ensuring thorough investigations and compliance.
Evaluated and processed coverage for policyholders, confirming and denying claims as necessary.
Coordinated communication between claimants, medical professionals, and legal representatives.
Oversaw the precertification process to facilitate timely treatment for claimants.
Maintained ongoing contact with claimants and attorneys to track treatment progress and outcomes.
Conducted training sessions for claims staff on best practices in claims assessment and resolution.
Prepared liability analyses and drafted denial letters, ensuring clear communication with all parties.
Experience
5-7 Years
Level
Senior
Education
B.S. in BA
Claims Support Specialist Resume
Objective : Talented Claims Support Specialist with 2 years of experience in managing insurance claim processes and ensuring accuracy in documentation. Proficient in client communication and problem resolution, dedicated to enhancing operational efficiency. Eager to leverage my analytical skills and commitment to customer service excellence to support a dynamic team.
Skills : Claims Documentation, Customer Relationship Management, Work Under Pressure, Claims Processing, Data Entry, Client Education
Description :
Collected and analyzed numerical data to support insurance claims.
Corrected discrepancies on foreclosure claims to ensure accuracy.
Documented claim payments accurately within the system.
Pre-audited accounts to verify satisfaction before closure.
Recognized for maintaining a high standard of claims processing efficiency.
Reduced claims errors by 90% through meticulous review processes.
Processed incoming faxes from clients and medical offices promptly.
Experience
0-2 Years
Level
Entry Level
Education
AABA
Claims Support Specialist Resume
Headline : Accomplished Claims Support Specialist with 7 years of experience in efficiently managing and resolving complex insurance claims. Proficient in conducting thorough investigations and ensuring compliance with regulatory standards. Committed to optimizing processes and enhancing client satisfaction through exceptional service and effective communication, while fostering strong relationships with stakeholders.
Skills : Claims Analysis, Insurance Regulations, Communication Skills, Negotiation Skills, Data Entry
Description :
Identified and resolved claim issues, including denials and adjustments, ensuring timely resolutions.
Coordinated with internal departments for thorough claims reviews.
Managed clerical tasks such as filing and correspondence related to claims.
Conducted appeals and disputes for denied claims, providing status updates as necessary.
Verified eligibility for health plan members, ensuring accurate claims processing.
Reviewed ICD-9 Procedure codes to determine authorization requirements.
Previewed outgoing checks for insurance payments, ensuring accuracy and compliance.
Experience
5-7 Years
Level
Executive
Education
B.S.B.A.
Claims Benefit Specialist Resume
Objective : Detail-oriented Claims Benefit Specialist with 5 years of experience in managing insurance claims and ensuring compliance with industry regulations. Proven ability to analyze complex claims, resolve discrepancies, and enhance operational workflows. Committed to delivering exceptional service and fostering positive relationships with clients and stakeholders.
Analyzed and approved routine claims that cannot be auto adjudicated, applying guidelines to resolve eligibility issues and discrepancies.
Processed reimbursement claims to Medicaid, ensuring compliance with regulatory standards.
Reviewed claims for accuracy, investigating and resolving billing discrepancies.
Triaged complex claims to senior specialists, ensuring adherence to coding and procedural guidelines.
Facilitated training sessions as a subject matter expert, enhancing team knowledge and performance.
Utilized advanced system functions for accurate and timely claims processing, including Claim Check and reasonable and customary data.
Managed claims for Fortune 500 companies, utilizing ACAS and Aetna intranet systems to ensure compliance and efficiency.
Experience
2-5 Years
Level
Executive
Education
B.S.B.A.
Claims Processing Specialist Resume
Objective : Insurance claims professional with 5 years of experience in efficiently managing and resolving claims. Expertise in thorough investigations, regulatory compliance, and enhancing operational workflows. Committed to delivering high-quality service and optimizing processes to ensure exceptional client satisfaction and operational success.
Processed repair claims, updating and confirming claims for both new and returning customers.
Reviewed claim and policy information to provide a solid foundation for thorough investigations.
Evaluated facts provided during investigations to determine liability and the company's obligation.
Established proof of loss by analyzing submitted documentation and gathering additional required information.
Resolved claims by approving or denying requests, calculating benefits due, and initiating payments.
Provided administrative support in the claims department, ensuring efficient operations.
Reviewed insurance claims for accuracy and completeness before submission to claims examiners.
Experience
2-5 Years
Level
Executive
Education
B.S.B.A.
Claims Processing Specialist Resume
Headline : Accomplished Claims Processing Specialist with 7 years of experience in efficiently managing and resolving complex insurance claims. Expertise in regulatory compliance, analytical assessments, and fostering strong client relationships. Committed to enhancing operational workflows and delivering exceptional service, consistently driving improvements in claims processing efficiency.
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