Claims Resume Samples

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M Jerde
136 Gottlieb Ramp
+1 (555) 560 1123
136 Gottlieb Ramp
p +1 (555) 560 1123
Experience Experience
Boston, MA
Claims Intern
Boston, MA
Boston, MA
Claims Intern
  • Assisting in the processing, investigating, and resolving claims. Research, survey, and provide follow up when necessary
  • Assist in simple claims processing work
  • Provide daily support to Allstate claims employees and assist with day to day activities including process, training, and communication
  • Assist in workflow review and streamline projects
  • Assist in generating letters and other correspondences
  • Will be assigned to a specific claims team with duties assigned by the Team Manager/Supervisor
  • Work with the telephone claims unit to follow claim processing routine
Boston, MA
Boston, MA
Reichert, Franecki and Prohaska
Boston, MA
  • Assist SIU management in providing claims fraud awareness training to the Regional Claims Office staff
  • Develop, analyze, and complete reports to submit to management on team performance
  • Develop, analyze, and prepare reports to submit to management on team performance
  • Makes assignments to nurse case management when indicated, monitoring their billing and performance
  • Collect and analyzes data to evaluate operational processes and makes recommendations to secure improvement
  • Collect and analyzes data to evaluate Medicate operational processes and make recommendations to secure improvement
  • Works closely with underwriting and risk engineering partners to provide feedback on policy forms and claim analysis
Boston, MA
Director of Claims
Boston, MA
Howe, King and Trantow
Boston, MA
Director of Claims
  • Manage according to established expense, reserve and settlement authority levels and internal claims policies established by the VP of captive management
  • At the direction of Claims VP, provide coaching, set expectations and manage the performance of the team
  • Develop close working relationships with risk managers, defense attorneys, internal staff, and vendors who support the claims operation
  • Oversees the management of day to day activity of the new day and rework claims teams
  • Effective problem solver, who anticipates issues, seeks out and analyzes information collaboratively to propose and implement solutions. Takes ownership for a successful resolution
  • Oversee the operational and technical work of the claims team and implement claim handling best practices to coordinate consistent and successful handling of all claims, especially claims with potential large exposure
  • Collaborative mind-set and willingness to work with people outside immediate reporting hierarchy to improve processes and generate optimal departmental efficiency
Education Education
Bachelor’s Degree in Related Field Preferred
Bachelor’s Degree in Related Field Preferred
Ohio University
Bachelor’s Degree in Related Field Preferred
Skills Skills
  • Excellent team player capable of learning and sharing knowledge in a global team environment
  • Team player demonstrating strong collaborative orientation with the ability to build strong relationships across the organization
  • Works within highly complex assignments requiring specialized knowledge in breadth and/or depth in area of expertise
  • Basic knowledge and experience working within a team environment
  • Ability to develop high performance teams and be a strong team player
  • Basic knowledge of developing and managing project work
  • Applies highly advanced knowledge of insurance policy, coverage, and regulation
  • Ability to investigate, evaluate and settle highly complex claims
  • Applies highly advanced knowledge of training facilitation and coaching skills
  • Applies highly advanced ability to leverage learned technical skills in support of team objectives
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15 Claims resume templates


Citishare Claims & Adjustments Manager Resume Examples & Samples

  • Acertain advanced knowledge in various software programs and expertise on 13 different network operating rules, regulations and requirements across all networks
  • Analyze and provide management MIS on exception volume to facilitate exception reduction
  • Develop impact analysis on third party operating rule changes and deliver settlement and exception processing training to TCSeServe and Citishare client base
  • Analyze Claims and Adjustment Unit processes in improving controls and to facilitating quarterly self-assessment in preparation of audit review
  • Manage internal processes to minimize financial risk to the business and Citigroup client base and to ensure regulatory compliance and or timing guidelines set forth by all third party processors
  • Manage settlement exception processing relationships with Citishare businesses and third party processors to ensure open and comprehensive communication
  • Broker partnerships and leverage existing alliances to ensure that high customer service standards are maintained
  • Provide day-to-day C&A oversight Management to TCSeServe to ensure incoming exceptions are accurately processed within network guidelines in mitigating potential losses to Citishare
  • Review eClaims in-box daily as part of management process to ensure no holdover
  • Complete STR and SMR to resolve the issues when internal applications and network online systems become unavailable which would potentially have negative impacts on productivity
  • Review the D&F differences on the aging report weekly and Arbitration reports to ensure timely follow-up to resolve any pending issues
  • Review monthly exception volume variance and annotate any fluctuations/root cause to management
  • Represent C&A department at STR meetings relative to vendor, system, network and production issues
  • Collaborate with third party networks or businesses in determining root cause and work with respective acquirer to implement fixes to minimize exceptions
  • Interface with project managers on new projects and document project requirement implication to ensure all task are tested by preparing test scripts; perform quality assurance testing and review output test results before project is implemented
  • Interface with external vendors ACI and Datajump to enhance internal systems upgrade to Claims Manager and eClaims. Analyze MIS yearly exception volume to reduce exception rate and cost to forecast budget plan for the unit
  • Prepare Management Summary report of C&A issues monthly
  • Manage / Approve the eClaims and RDP user entitlement request through Market Place
  • Manage risk and drives productivity based on best practices
  • Achieve zero write-offs by providing oversight to TCS Management Team
  • Manage C&A eClaims system and perform UAT testing for projects and network migrations
  • Update Citishare Operating Rules and reviews supervisor updated PCMs network operating rules in accordance to product revisions and/or changes of practices in the industry. Notify the businesses for them to implement these changes on their internal systems if necessary. Deliver settlement and exception processing training to staff and business client base
  • Collaborate with external vendor Datajump on internal system upgrades such as eClaims
  • Act as the primary backup to update the eClaims Admin tables with new Clients and Networks
  • Perform Annual COB Test for South West Data Center
  • Provide backup support across Operational Service Units (Customer Service, Change Control, Info Center and Business Support) as required
  • Strong experience in EFT settlement and back office operations
  • Customer service investigation experience
  • Banking knowledge
  • Accounting skills
  • Accounting – 1 to 2 years
  • Banking/Operations for ATM / POS - 3 to 5 years
  • MS OFFICE suite: Excel, Word, Power Point
  • SQL Data

AVP, Ontario Claims Resume Examples & Samples

  • Ensure a consistent legendary customer experience at every interaction aligned with the TD Brand
  • Contribute to making TDI a world class organization recognized as being an exceptional place to work
  • Deliver, in partnership with Claims Executive team, key metrics around Customer and Employee Experience, Operational Excellence and delivering on our financial commitments
  • Proven operations leadership is critical, along with a solid understanding of the Customer Experience, Customer Problem Resolution and the Customer Experience Model
  • Identify and make recommendations for business/process improvements while working with various business partners across TDI
  • Possess the ability to guide others to a desired conclusion and have the ability to hold them accountable
  • Devote time and energy to developing Senior Managers and Managers, specifically adhering to the Performance Management Practices and Leadership Profile, by coaching and supporting direct reports in reaching their objectives and delivering business results and an exceptional employee experience

Senior Living Claims Director Chicago Resume Examples & Samples

  • Responsible for input on development and execution of the strategies of the practice
  • Monitors and improves the performance of trading partner’s services for your clients
  • Participates in strategic large client meetings as required
  • Manages the quality and appropriateness of client service agreements
  • Ensures appropriate program design and documentation - service scope aligns

Multinational Claims Resume Examples & Samples

  • · Development of annual claim service plans including reaching agreement of special handling instructions and reporting procedures with applicable claim service providers and issuing documents to clients
  • · Coordination of Aon claim team members assigned at the country level
  • Coordination, collection and presentation of claim data on behalf of client corporate risk management.Participate in on-site claim audits
  • Desk Based advice to client on claim matters, status and coverage interpretation
  • Coordination of the escalation of sensitive claims with carriers, third parties administrators and adjusters, all subject to Aon’s formal protocols
  • · Identification of opportunities for the introductions of Aon Claims and/or risk control consulting services, the scope of which is beyond the base service

Global Captive Claims Resume Examples & Samples

  • Manage time spent in the delivery of agreed client services to ensure content quality, timely delivery, and profitability
  • Meet or exceed assigned billable hours and utilization goals
  • Communicate and collaborate with manager and captive managers to identify opportunities for new business development
  • Establish rapport and maintain positive working relationship with clients and colleagues
  • Adhere to established Best Practices and make recommendations for improvement, when appropriate
  • Maintain knowledge/skills as an insurance professional and possess excellent written and verbal communication skills
  • Participate in telephonic or in-person claim reviews and audits designed to result in file resolution, inclusive of documenting claim specific outcomes and action plans
  • Attend and participate in periodic on-site client meetings regarding service delivery and/or stewardship

Claims Processing Specialist Resume Examples & Samples

  • Review source documents for completeness and accuracy. Compare information in system against source documents to ensure accuracy
  • Enter data into computer accurately and within established time frames
  • Resolve problem claims not accepted by system edits and audits as appropriate
  • Perform research as appropriate to resolve claims issues. Make determinations utilizing both SOPs(Standard Operation Procedures manuals) and on line help screens
  • Achieve and maintain established production and quality standards
  • Follow up on processing issues and make suggestions for system efficiencies
  • High School Diploma or equivalent; may hold post-high school Degree
  • Six to 1 year of working experience in related fields (Medical Billing or Claims processing )
  • Some office experience, computer experience or data entry skills,
  • Some healthcare related knowledge
  • Ability to read and interpret moderately complex documents such as procedure manuals, and government/healthcare guidelines

Motor Claims Resume Examples & Samples

  • Analysis of first notification of Own Damage and Third Party liability claims
  • Pro-active treatment and settlement of claims
  • Manages portfolio of claims allocated
  • Controls cost through identification of potentially fraudulent cases and recovery cases
  • Works flexibly in the Motor Claims Team to meet customer needs
  • Operate within Service Level Agreements and Claims compliance deadlines
  • Undertakes special projects or assignments as required

Claims Operational Excellence Manager Resume Examples & Samples

  • May lead team in addition to leading cross-functional project teams to drive process improvements within the business. Responsibilities include scheduling and facilitating project team meetings, developing project plans to include identification of key deliverables and timelines, summarizing and communicating project status, training and coaching project team in the use of Six Sigma tools. Generally accountable for projects expected to have significant client impact and/or greatest margin improvement
  • Employ structured methodology and analytics to problem identification and solution process; utilize data analysis techniques to identify process improvement opportunities and develop solutions for the business. Mentors and coaches other, less experienced Black Belts on the appropriate use of Six Sigma tools
  • Employ consultative techniques in uncovering and assessing process improvement opportunities within the organization through dialogue with operational leaders and team members. Categorize process improvement opportunity as either enhancement to client experience or margin improvement; ensure alignment with Client Service strategy and objectives. Propose improvement recommendations to the leadership team
  • Facilitate the adoption of a process improvement culture and practice within the business. Prepare a thorough analysis of downstream impacts of project deliverables, identifying all impacted areas and stakeholders; partner with other organizations such as finance, compliance, technology, etc
  • Facilitate the integration of a culture that incorporates efficiency and productivity/performance improvement to operating procedures throughout the organization by providing formal training programs or utilizing more informal communication methods
  • Develop key metrics of success and track accordingly. Monitor project cost and progress in project deliverables. Track project outcomes relative to financial saves; ensure documentation to project planning system and incorporation of financial saves to departmental budgets
  • Strong project leadership skills with demonstrated experience analyzing business processes; history must demonstrate successful project coordination
  • Demonstrated interpersonal and written communication skills; able to work effectively with all levels of staff and cross-organizationally
  • Exhibits strong affinity toward training and mentoring others to build capabilities in process improvement methodology
  • Previous people leadership or coaching experience
  • Six Sigma Black Belt or Lean Process experience

Unemployment Claims Lead Resume Examples & Samples

  • Serves as primary contact directing and consulting with partners, managers, partner resource generalists throughout the organization and external parties on matters related to unemployment insurance
  • Assists the manager with departmental staffing decisions and ensures smooth partner on-boarding Participates in departmental strategic planning
  • Contributes to the development and tracking of department metrics and key performance indicators to measure team and individual performance
  • Maintains a high level of proficiency in company unemployment insurance objectives. Performs research and analysis to maintain expertise in state unemployment policies, laws, and regulations
  • Supports and executes team training for new partners as well as driving ongoing learning opportunities for the team
  • Identifies and implements recommendations for continuous process improvements and actively supports the ideas of others
  • Acts as a floor coach ensuring accurate information is being communicated, answering questions and handling escalated calls and cases for timely resolution and customer satisfaction
  • Analyzes and resolves complex or escalated issues
  • Responds and ensures timely, courteous and professional follow up to all incoming case documentation and communication to completion. Manages specialized and senior level partner unemployment claims
  • Audits the quality of information provided to the state and prepares related reports
  • Assigns work and reviews work product, ensures all claim deadlines are met, determines additional resources, if needed and supports service levels by taking escalated calls
  • Develops partner knowledge to build a strong and knowledgeable team
  • Supports vendor compliance and serves as a primary contact for vendor communication
  • Lead or supervisory experience (1 year)
  • Project or program management (1 year)
  • Customer service experience (2 years)
  • General Human Resources (3 years)
  • Case management experience (3 years)
  • Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Visio, Microsoft Project)
  • Ability to deliver strong customer service
  • Ability to organize work and manage time
  • Ability to handle sensitive information and maintain confidentiality

Avp Claims Americas Resume Examples & Samples

  • Manage a team of highly skilled professionals within the global organization
  • Develop the strategic vision of the department and implement the necessary action plan to improve interactions and service quality optimizing resources
  • Motivate and inspire the Claims professionals within the Americas Region
  • Ensure the application of corporate guidance from the Worldwide Claims Substantiation
  • Participate in the development of Worldwide Claims Substantiation guidelines and processes
  • Liaise with Legal Department, when claims related issues are at stake, both in demand and in response
  • Communicate and promote Claims Substantiation for the Americas for all stakeholders
  • Partner with senior management on issues related to claims in terms of company responses and positions
  • Minimum of ten years industry experience (cosmetics, personal care products, pharmaceuticals or food). Specific experience in claims substantiation required
  • Juris Doctor degee is required
  • Must have prior leadership experience
  • Advanced communication, leadership and influencing skills
  • Participation in various technical & liaison organizations within the industry
  • Excellent organizational skills and the ability to handle multiple tasks
  • Able to interact successfully within an R&I environment
  • Experience working in a Global Organization
  • Multi-lingual - In addition to English fluency, Spanish is strongly preferred. Portuguese and/or French would also be a plus
  • Must be legally eligible to work in the US on an on-going basis

Initial Claims Processing Specialist Resume Examples & Samples

  • Proficiency in Microsoft Office Word, PowerPoint, and Excel
  • Ability to maintain a good attendance record and possess a desire to learn
  • Prior experience with initial claims processing
  • Experience working in a call center environment and/or customer service environment
  • Prior experience in the health insurance industry
  • College degree or some college coursework

Claims Divisional Manager Resume Examples & Samples

  • Maintains and controls proper technical authorities/experts throughout the division and personally handles escalated client complaint issues
  • Assists senior leaders in areas of development regarding system enhancements, technology enhancements, vendor selection, and departmental workflow
  • 5+ years of auto claims handling
  • Strong leadership skills that includes effective coaching and collaboration
  • Presents issues in a highly professional manner; excellent communication skills-both verbal and written
  • Solid understanding of regulatory environment and state statutes that affect the insurance industry; ability to translate this knowledge to procedures

Claims Complaint Specialist Resume Examples & Samples

  • Formulates DOI/BBB complaint responses, addressing all concerns and gather all necessary documents to file a complete and timely response meeting all state requirements. Ensure all responses are accurate and objective. Partner with Claim Leaders on all responses
  • Investigate and monitor complaints to ensure compliant business practices are being followed. Work with Claim Leaders and the Training Manager to close identified gaps
  • Work with the AAH compliance area as well as Claims Compliance on any research needed of applicable laws and regulations
  • Complete reports around analysis and trending of complaints. Complete other reports requested by internal business area as needed
  • 3-5 years of relevant claim experience
  • Strong verbal communication and interpersonal skills
  • Continuous desire to learn
  • Associate in Claims-designation-Am Institute of Chartered Property Casualty Underwriters

Manager, Guest Claims Resume Examples & Samples

  • Compliance with federal and industry guidelines
  • Fostering and maintaining positive relationships with key stakeholders, partners, vendors, and regulatory agencies
  • Oversight of department budget and forecasting
  • Recognizing and responding to incidents that have significant exposure
  • Management of claim-level and aggregate financials
  • Strategic business planning and implementation
  • Adherence to excess policy and reporting requirements
  • Development and oversight of a team in excess of 25 Cast Members
  • Florida 520 License in Good Standing
  • Proven accomplishment as a leader
  • Proactive communicator who can interface effectively at all levels in the company and can appropriately influence business results through negotiation, persuasion and personal presence
  • Possess unquestioned ethics and integrity
  • Demonstrated compassion and commitment to diversity and inclusion including inviting diverse
  • Demonstrated strong partnering skills that result in a positive business results
  • Demonstrated strong analytical skills and ability to synthesize various sources of information
  • Demonstrated strong organizational skills with attention to detail
  • Demonstrated understanding of medical and legal terminology
  • Bachelor’s Degree in Business, Risk Management, or associated field, or a minimum of 15 years Florida Liability Claims Management experience of which 5 years were in a leadership role

Claims Spec / Asst Resume Examples & Samples

  • Receive calls and emails from insured’s, beneficiaries, agents, attorneys and funeral directors who are calling to report or inquire about the status of a claims (average 150 calls per person per week)
  • Prepare new claim file with information for the Examiner who will pay/deny the claim
  • High school education needed along with 0-2 years of experience with computers and insurance background
  • Knowledge of claims process
  • Skills Advantage Work Ready Certificate, Optional. Above average telephone and customer service skills, legal terminology, dependability and strong organizational skills
  • Knowledge of the claims department, other departments within the company and the other offices that form Transamerica would be helpful

Claims Cost Mgmt New Opportunity Manager Resume Examples & Samples

  • Lead a team of highly motivated associates to uncover new cost savings concepts utilizing the latest methods and technologies that are available in the industry
  • Work side by side with the entire Claims Cost Management dept. to ensure all overpayments are actively pursued and every angle is researched
  • Network with peers within Humana and the industry to stay on top of the latest concepts, contracts, edits, etc that are put into place in the healthcare field
  • Work with multiple business partners to identify and pursue all opportunities where Humana and the healthcare industry are at risk
  • Report activities and progress towards goals and objectives within CCM and ensure that objectives stay aligned with department goals
  • Must be highly organized yet flexible to always adapt to the everyday changing business environment in Claims Cost Management
  • Always looking for ways to improve processes and improve efficiencies. Inspire team to act and improve current models and ways of doing business and look for the next new idea
  • Proven reporting and organization skills
  • Demonstrated success working in collaboration with multiple departments and disciplines
  • Strong computer skills including MS Office desktop applications (Word, Excel, PowerPoint)
  • Demonstrated competency in both oral and written communication skills
  • Solid understanding of process / work flow concepts
  • Excellent interpersonal and teamwork skills
  • Master’s Degree in Business, Finance or related fields
  • Humana Claims experience (CAS or Metavance)
  • Previous experience successfully identifying fraud, waste, abuse or overpayment situations/concepts
  • Healthcare claims processing experience

Senior Systems Manager, Medicaid Claims Resume Examples & Samples

  • Has very strong domain working expertise with Medicaid
  • Must have strong functional expertise and understanding of Medicaid claims and its end to end lifecycle
  • Has working knowledge of healthcare EDI transactions
  • Has working knowledge of healthcare administration, preferably within the government environment
  • Must be able to conduct in-depth functional discussion with client’s IT and Operational SMEs
  • Must know end to end Medicaid system and business operations to be able to help steer client, IT and Operations team to implement policy related system changes
  • Constantly look for federal and state level regulatory compliance needs and work with account manager to make proposal for system enhancements/process upgrade to keep system and business process compliant with changing needs
  • Four (4) year degree from accredited college or university
  • Bachelor’s / Master’s degree in computer science or related area of studies are a plus
  • Minimum of 8 years of hands on project management experience with direct responsibility and ownership of the project
  • Minimum of at least 5 years in a leadership role for a government or private sector health care organization
  • Previous, recent, and successful experience with MMIS (or equivalent) or MMIS claims expertise is required
  • Proficient with Microsoft Office and MS Project like tools
  • Experience on .net architecture and technology is a plus
  • Has working experience of managing multiple vendor based delivery teams
  • Has working experience of writing contract to outsource work

Claims Processing Specialist Resume Examples & Samples

  • Proficiency in all Microsoft Office Programs, including Word, PowerPoint, Excel
  • Related work experience
  • College degree or some college coursework preferred
  • Fluency in Spanish

Claims Processing Specialist Resume Examples & Samples

  • Read and understand insurance benefits to estimate coverage and patient out of pocket responsibility
  • Ability to meet quality and efficiency metrics in a production environment
  • Some customer service duties with the majority of your work on the computer
  • Documenting case files with complete notes on work
  • Complete special projects as needed
  • Organized and attentive to details
  • Proactive, positive attitude
  • Ability to work the hours stated below
  • Previous Medical Insurance experience

Team Member, Claims Contact Centre Resume Examples & Samples

  • Responsible for the assessment, management and administration of a portfolio of risk product claims within delegated authority to achieve profitability targets
  • Ensure claims are actively managed to by ensuring appropriate investigations are undertaken such as medical, financial and factual
  • Manage FOS, SCT and Litigated Claims (in conjunction with relevant stakeholders), including drafting of written responses
  • Meet specified quality and service standards
  • Effectively and pro-actively communicate with both internal and external stakeholders to build strong relationships
  • Provide technical training and assistance to new members of staff
  • Act as a point of reference for technical queries including assistance with documentation of guidelines and procedures where required
  • Contribute to presentations where required
  • Assist with reporting and internal/external audits where required
  • Support management direction and change processes – acting as an advocate within the team as necessary, and participation in projects as directed by Team Leaders
  • Actively participate in Projects including system enhancements and UAT testing where required
  • Encourage innovation and problem solving
  • You will have come from a contact centre environment
  • Experience in AWD and Eclipse would be an advantage
  • Knowledge of claims processes, definitions under policies, techniques in claims investigation

Team Lead, Claims Resume Examples & Samples

  • Bachelors Degree preferred but not required
  • Prior experience with Claim Management processes preferred
  • Proficiency in MS Word and Excel required
  • Strong critical thinking, mathematical, problem solving, decision making & analytical skills are desired
  • Detail oriented with solid interpersonal skills
  • Demonstrated strong Customer Service skills
  • Willing to consider someone with a strong retail or operations management background that is interested in gaining a knowledge of Group Insurance products.**

Common Depositary Claims Resume Examples & Samples

  • Provide respective ICSD’s with timely and accurate responses to daily queries
  • Review and reconcile any data discrepancies with Euroclear and Clearstream in advance of upcoming scheduled payments
  • Provide Euroclear and Clearstream with timely feedback on a daily basis for all data discrepancies
  • Provide a central point of contact for Euroclear and Clearstream Income teams
  • Participation in weekly / monthly client service conference call’s
  • Accurate logging of all queries/responsible area and closure date leading to provision of daily metrics with sound analysis of fluctuations
  • Assistance in completion of all daily processes/deliverables across Depositary team
  • Provision of weekly metrics with sound analysis of fluctuations
  • Working closely with team leader to identify areas of operational risk and co-writing system of checklist to minimise risk; reviewing and signing checklists daily
  • Provision/submission of Monthly Management Control Assessment (MCA) paperwork
  • Leads and/or participates in projects as directed by the Team Leader/Section Manager and provide feedback on project related activities
  • Provide progress reports and support to Team Leader as required
  • Participate in any root cause analysis on a daily basis
  • Initiative is essential
  • Strong organisational skills and an ability to work accurately under pressure
  • Ability to work within a team dealing with high volumes
  • Ability to work under pressure and meet strict deadlines
  • Highly productive with good organisational/time management skills
  • Ideally from an Operations background with sound understanding of securities
  • Good understanding of general MS software packages (Excel, Word, and Outlook)
  • Knowledge of Euroclear and Clearstream would be advantageous
  • Knowledge of Product type / structures, documentation, swift formats would be advantageous

Claims Case Manager Resume Examples & Samples

  • Answer the 1-800 ITVERP Resource Line, responding to and assisting victims of international terrorism
  • Process victim applications for reimbursement, including but not limited to, drafting and mailing claimant, collateral source and provider correspondence
  • Enter and track all claims activity into Excel based tracking systems
  • Interact regularly with victims of international terrorism
  • Draft expense summary sheets in Excel for claim recommendations
  • Draft meeting minutes, after action minutes, and weekly reports for Program Manager review
  • Participate in and contribute to weekly case management meetings
  • Maintain daily operations of the claims management process
  • Respond to data requests in a timely matter
  • Interact professionally with diverse government officials, including but not limited to, the Department of State, the Federal Bureau of Investigation, and the National Security Division within the Department of Justice
  • Bachelor’s degree in Social Work, Psychology, Sociology, Counseling, Mental Health, Anthropology, Education, or other Social Science related discipline required
  • 2+ years of government based, client, or customer facing experience in the social sciences field
  • Experience interacting professionally with a wide variety of stakeholders
  • Experience drafting diverse documents (i.e. letters, reports, correspondence, and claim recommendations)
  • Proficiency with Microsoft Office (Word, Excel, and PowerPoint)
  • Ability to obtain a Department of Justice security clearance, which involves a criminal background and credit check
  • Previous experience with client management highly preferred
  • Experience working in a consulting environment and with government programs preferred
  • Demonstrate immaculate attention to detail
  • Ability to produce high quality work required
  • Ability to be flexible, multi-task, prioritize, detail-oriented, and manage multiple activities simultaneously in a fast-paced, changing environment
  • Experience working directly with victims of crime
  • Ability to speak another language fluently
  • Experience processing claims
  • Experience working in the field of international terrorism
  • Demonstrate commitment to client satisfaction
  • Ability to exercise good judgment, discretion, tact, and diplomacy
  • Solid customer service skills
  • Strong team player with the ability to take initiative and work well independently
  • Strong outreach abilities and interpersonal skills

Director, Claims Oversight Resume Examples & Samples

  • Motivate management staff and subcontractors to effectively manage their departments to consistently meet quality and production goals
  • Promote total quality management by challenging staff and subcontractors to evaluate processes and modify as business needs changes while staying within budget
  • Evaluate system technology and develop strategic plans to determine changes which meet the customer’s needs and work with other departments to implement
  • Develop and maintain relationships with other departments within Humana Government Business, Inc., subcontractors, markets, DHA and TRO Staff
  • Effectively leverages resources to create exceptional outcomes, embraces change, and constructively resolves barriers and role essentials
  • Perform special projects and other duties as assigned by management
  • Maintain trend performance data to identify adverse outcomes and root causes
  • Meet with government representatives, beneficiary or provider groups to address claims and operational issues and provide a pro-active communication plan
  • 8-10 years management experience in medical insurance industry with direct claims and/or systems
  • Goal and result oriented with proven track record
  • Project management and decision making skills
  • 5-10 Years of health care industry knowledge in Medicare or TRICARE
  • 5 Years of Claims Operations knowledge
  • Mater's degree

Claims Case Manager Resume Examples & Samples

  • Completes follow-ups with Claimants (Claimant Feedback Tool)
  • Provides ongoing updates to the ITVERP Operation Manual and ITVERP Policy Manual
  • Drafts revisions/updates to ITVERP standardized forms/templates or memos as needed, and submits to PM review

Claims Resume Examples & Samples

  • Minimum of Bachelor’s degree and 10 years’ experience in ski resort industry. Prior hospitality and amusement industry experience a plus
  • Must be an advanced level skier/rider
  • Written and verbal skills paramount. Must be a polished public speaker and comfortable addressing crowds large and small
  • Must be familiar with Microsoft suite of products and comfortable using/exploring new software programs
  • Must be able to work independently, take initiative, develop relationships and execute plans with clients, carrier partners, and industry associations
  • Strong decision-making skills essential

Claims Director Resume Examples & Samples

  • Ensure the team to meet business goals, specifically financial targets, with a long-term focus on sustainability and strategic objectives
  • Proactively engage with and influence stakeholders internally and externally to gather insights and facilitate alignment of deliverables and utilize available resources
  • Enhance the technical skills of claim assessors by compiling the claims guidelines and provision of training programs
  • Participate in new product development by reviewing policy provisions, product brochure and product materials, setting claim administrative guidelines, training to assessors and reviewing claim forms
  • Assist in reviewing claims procedures and guidelines and ensuring regulatory changes are adopted
  • Provide training on claims guidelines and procedures to distribution channels
  • Keep updated of market information and share the best practice with the team
  • Lead any ad hoc project as assigned
  • Minimum of 12 years solid individual life or medical claim assessment experience with at least 6 years in leading assessment teams
  • Degree from a recognized University
  • Professional qualification in life insurance including FLMI (Fellow, Life Management Institute), ALHC (Associate, Life and Health Claims), ACS (Associate, Customer Service) would be an advantage
  • Proven leadership, people management and problem solving skills
  • Attentive to details with strong analytical and presentation skills
  • Strong communication skills, able to communicate well in both business and technical aspects with people from at different levels
  • Proficiency in written and spoken English and Chinese
  • Good PC knowledge in MS Excel, Word and PowerPoint

FCD Claims Resume Examples & Samples

  • Responsible for the overall management, coordination and maintenance of one of the major segment of the Bank's operations activities
  • Assist in the formulation, recommendation and implementation of operations policies
  • Direct the study and establishment of new and revised systems, procedures, methods, and forms
  • Accountable for budget management
  • May be responsible for cross-site / function project leadership
  • May serve as center manager for site
  • Has the ability to influence across department / site
  • Have impact on the Bank's earnings, operation or image and a major impact on the functional area
  • Ensure assigned area(s) are adequately staffed and all personnel are trained and developed
  • Work with peers throughout the Bank to develop, enhance and implement business strategies
  • Build external relationships in functional area
  • 8+ years of operational management experience with at least 5 years in call center environment (virtual network/call routing environment)
  • Exceptional leadership skills in creating an environment where employees are excited, engaged and capable of delivering optimum performance
  • Proven communication and diplomacy skills to work cross-functionally to influence others, drive results/change, and implement projects/processes
  • Experience in credit/debit card investigation and chargeback processing with knowledge of Visa/MasterCard rules and regulations
  • Extensive fraud knowledge and background preferred
  • Strong PC skills in Microsoft Office and specific knowledge of systems and applications used to support a call center environment

Claims Professional Resume Examples & Samples

  • Preparation for and participation at claims reviews
  • Analysis of claims data and reserve exposures
  • Identifying and promoting action on opportunities for claim cost mitigation
  • Participation in client / carrier meetings
  • Ongoing communication with internal clients to best support the renewal process, program close out process and other duties as needed
  • Travel required (25-30%)
  • 7 -10 years of experience with a carrier or third-party administrator adjusting worker’s
  • Broker, construction claim experience, and experience working with multi-state worker’s compensation jurisdictions would be a plus

Claims Professional Resume Examples & Samples

  • Position is currently located in Jericho, NY and will be relocated to Garden City, NY – Fall 2016
  • Proficiency with MS Office suite products (Word and Excel)
  • 5 -10 years of experience with a carrier or third-party administrator adjusting worker’s

Claims Specialists Resume Examples & Samples

  • Has intermediate computer skills including: word processing, spreadsheet and powerpoint software
  • System savvy, attention to detail and action orientated person
  • Possesses strong written and verbal communication skills in both English and Mandarin

Manager, Casualty Claims Resume Examples & Samples

  • Oversight of claim activities for operations in all 50 states and Canada, representing over 2,300 open claims with $134 million incurred costs
  • Serve as point of contact to OPCO and TPA for claims management responsibility
  • Manage, maintain and enhance the partnership with Third Party Admistrators (TPA)
  • Monitor claim files for exectuation of appropriate claim handling and reserving practices while providing technical support and oversight
  • Collaborate on action plans for claim settlements within specific financial thresholds
  • Communicate and coordinate new policies and procedures & implementation between Sysco and TPA
  • Provide support with Corporate Safety Services and Enterprise Risk Management team to align strategies and goals to minimize incidents and costs
  • Generate and analyze claims loss runs and reports to identify and communicate trends
  • Communicate status of claims, claims cost and reserve information to OPCO as necessary
  • Serve as Corporate claims representative on all initial serious claims calls and telephonic claim reviews
  • Attend trials, mediations, arbitrations, hearings and other forums as needed
  • Partner with OPCO HR managers to ensure timely and appropriate Return to Work (RTW) for associates with or without restrictions
  • Determines actual time missed from work due to work related injuries and illnesses and provides accurate information to both the OPCO and TPA to ensure accurate DART tracking
  • Bachelor’s Business Administration Degree required and or equivalent combination of education and experience
  • Ongoing continuing education courses required
  • 5 years’ claim adjusting experience with an insurance company or TPA dealing with high volume multi-jurisdictional workers’ compensation, general liability and auto liability claims and two years of experience with a large employer
  • Excellent analytical and interpersonal communication skills
  • Ability to interact effectively all levels
  • Excellent presentation and team building skills
  • Thorough understanding of the casualty claim process
  • Strong understanding of medical and legal terminology
  • Strong critical thinking ability, attention to detail and ability to multi-task in a fast paced environment
  • Promote teamwork and quality service through daily comunication and coordination with other departments

Claims Senior Service Specialist Resume Examples & Samples

  • Provides back-up for any support functions in the office
  • Investigate prior losses and other information on file and orders reports as needed at the direction of adjusters and managementReceives, screens and routes incoming telephone calls and other electronic correspondence
  • Prior experience providing excellent customer service experience in an office environment preferred
  • Ability to perform routine tasks of basic complexity under general supervision
  • Fluency in both Spanish and English is especially desirable

Claims Intern Resume Examples & Samples

  • Gain exposure to the overall Claims operation
  • Provide daily support to Allstate claims employees and assist with day to day activities including process, training, and communication
  • Currently in good academic standing, pursuing a Bachelors degree graduating in December 2016 or Spring 2017

Claims Liability Intern Resume Examples & Samples

  • Candidates should possess the following skills, experience, and attributes
  • Demonstrates strong verbal and written communication skills
  • Ability to work both on a team and independently and with integrity

Expense Claims Solutions Team Lead Resume Examples & Samples

  • Manage and coordinate a team of business analysts
  • Handle the operating budget and planning of the team (allocation of resources, recruiting, reporting)
  • Ensure proper functional analysis and process definition in line with Expense Claims Core Model
  • Manage deployment projects, tools enhancements and major incidents (Project Management and roadmap, release management and major incident reporting)
  • Prepare and participate to governance committees with IT, Group Finance, the Businesses and Concur Third-Party
  • Master’s degree in Finance or Business
  • Professional experience: Minimum 3 years of experience as a manager of small teams in the field of Cost Accounting or Finance
  • Experience in managing and maintaining Finance or Accounting tools
  • Experience using Concur Expense software or equivalent tools a plus
  • Experience using ERP or other similar general ledgers is a plus
  • Fluent in French (minimum B2 Level, CECRL certificate)
  • Leadership & Coaching skills
  • Quick self-starter, pro-active attitude with ability to work in a fast changing environment and with international locations
  • Strong communication skills (spoken & written)
  • Strong analytical mind, problem solving, planning & organisation skills
  • Ability to work under tight deadlines

Senior Director / Director, IFP Claims Resume Examples & Samples

  • Ensures that the Underwriting and Claims Management Policy and the Claims Standards set out in the Product Risk Management Manual are implemented within the business unit, where applicable. The implementation includes developing more detailed claims guidelines that are appropriate for the business unit’s specific business. Also, ensures claims staffs’ compliance with the detailed claims guidelines
  • Oversees Claims participation in product development to ensure that any claims concerns are raised and that Claims practices are appropriate to the product’s target markets and pricing assumptions
  • Ensures that the department’s claims practices and procedures align with the International Claims Association’s Statement of Principles
  • Participates in the selection of reinsurer(s) and in reinsurance treaty negotiation
  • Ensures treaty documentation reflects Manulife’s standards for claims and ensures compliance with treaties
  • Maintains excellent relationship with reinsurers
  • Provides leadership and direction in the hiring, professional development and training of the claims staff in order to maintain Manulife’s reputation as a recognized and experienced leader in insurance industry
  • Responsible for determining appropriate levels of claims approval limits for all lines of business. This includes recommending changes to the maximum approval limits for any level of claims staff to Underwriting & Claims Risk Management. Also, responsible for ensuring that delegation of approval limits to each claims staff are based on established criteria that is clearly communicated ad monitored
  • Responsible for the internal audit process of the Claims Department, ensuring that the audits are conducted in accordance with standards agreed upon with Underwriting & Claims Risk Management and the Underwriting & Claims Risk Committee. Ensures that audits finding and trends are reported to Underwriting & Claims Risk Management semiannually
  • Oversees that the risk(s) is understood from the outsourcing of claims business functions, activities or services to affiliates or third parties. Ensures that there is effective identification, mitigation, management and monitoring of all inherent risks associated with outsourcing and that they are managed in a manner consistent with all applicable policies
  • Oversees ongoing monitoring of claims trends sharing any changes, e.g. increases in incidence, increase in contestable claims, etc, with management within the BU, including Underwriting and Pricing
  • Active in industry committees, forums, meetings, etc. representing the Company to industry peers and distributors. Keeps abreast of emerging issues/trends, including litigation and arbitration trends, and regulatory changes that impact claims revising detailed claims guidelines as necessary. Ensures that claims staff is made aware of such changes and comply with them. Advises Underwriting & Claims Risk Management of any emerging issue/trend, including litigation and arbitration trends, or regulatory changes that could have implication for other Manulife business units
  • Shares with Underwriting & Claims Risk Management and the Underwriting & Claims Risk Committee claims fraud situations and where available and applicable, will share findings such as the operations and financial impact of them, the lessons learned from them and the actions taken within the business unit, division, globally
  • Reviews and signs the completed annual Claims Self-Assessment Questionnaire prior to submitting it to Underwriting & Claims Risk Management on a timely basis
  • Develops and maintains excellent relationships with all affiliates, third parties and business partners in order to build confidence in and promote Manulife’s strengths including claims as a core competency
  • Proven track record for strategic planning, tactical management and results driven successes
  • Strong operational management background
  • Strong relationship management skills, internal and external
  • Sound decision making skills
  • Excellent negotiating and influencing skills
  • Ability to interact with all levels of senior management
  • Excellent presentations skills. Able to present concepts and knowledge in an effective manner to Claims Professionals, Industry Leaders, and business partners who may or may not have an understanding of Claims
  • Post-secondary education required
  • Generally, need 10+ years of claims experience; however, this may vary based on education, training and business unit’s market

Senior Manager Group Life Claims Resume Examples & Samples

  • Manage work flows, processes and plan resources to achieve superior service -Handle escalated claims in a professional and empathic manner
  • Responsible for improving service through analysis of performance and implementation of continuous improvement initiatives
  • Build strong relationships with the sales force, customers and other business partners
  • Work in partnership with members of leadership team to ensure priorities are clear and are in line with business strategies
  • Participates in projects as a representative for their team. Competencies
  • Excellent leadership skills with the ability to influence others
  • In depth knowledge and experience of insurance business and claims
  • Strong decision making skills and customer service focus
  • Ability to motivate and develop staff to achieve high quality and service standards
  • Strong problem resolution skills
  • Experience and proven capability in initiating process improvements and implementing change
  • University degree or equivalent work experience
  • Minimum of 5 years in a leadership role
  • Experience in dealing with customers/advisors
  • Insurance knowledge

Claims Liaison Resume Examples & Samples

  • Document, track and resolve all plan providers’ billing and payment issues
  • Research verbal and written providers’ claims inquiries
  • Collaborate with various business units to resolve claims issues and provide instruction to providers’ billing staff and services regarding claims submission policies and procedures to ensure prompt and accurate claims adjudication
  • Identify authorization issues and trends
  • Direct and educate Provider Services and Relations with the claims reprocessing notification, utilizing knowledge of provider billing and claims processing
  • Analyze trends in claims processing issues and assist in identifying and quantifying issues and reviewing work processes
  • Identify providers experiencing a large number of claims issues or with the potential to develop claims issues and proactively work to eliminate barriers for accurate and timely claims processing
  • Identify potential and documented eligibility issues and notify applicable departments to resolve
  • Meet with providers to discuss claims payment policies and procedures and resolve claims issues
  • Handle provider additions, changes and terminations as identified
  • Run claims reports regularly through provider information systems

Claims Senior Manager Resume Examples & Samples

  • *Please note that this position is located at Banner Corporate Center Mesa off Country Club & Brown. It is not located in Phoenix, AZ
  • Supervises the operations of all reimbursement services for third party, ERISA, commercial risk, capitation, and third party administrator contracts. Develops, manages and maintains work processes and procedures for the companys benefits plan eligibility, capitation payments, claims adjudication, processing and reimbursement services
  • Selects, trains, coaches, motivates, conducts performance evaluations, and directs the workflow for the assigned Reimbursement Services staff. Develops goals and performance expectations for staff and manages staff performance
  • Maintains all required records. Supervises and coordinates the maintenance of all aspects of internal records associated with the departments management information and claims payment system. Responsible for maintaining department reporting obligations to internal and external constituents
  • Maintains a current and thorough knowledge of the Summary Plans Descriptions for each health plan serviced, and provides training, resources and information to the claims staff to enable the correct and timely adjudication of all provider and member claims
  • Meets organization criterion related to claims turn-around, quality, and provider payment requirements. Accountable for ensuring high performance outcomes through an integrated process of operational, quality, medical cost and resource management
  • Supervises human and material resources needed to maintain or exceed department standards. Participates in the development of the department budget in conjunction with established goals and objectives. Plays a key role in ensuring budgetary goals are met on an annual basis
  • Manages monthly capitation payment determination and payment distribution for all providers with current capitation contracts
  • Manages daily payment and check processing and distribution for all claims and capitation payments for the companys reimbursement services

Claims Team Member Resume Examples & Samples

  • Demonstrates experience and a proven track record in Payer-specific (Medicare, MediCal, Medicaid, and/or Private) Claims in a facility of significant size and complexity, hospital business operations, information systems, and patient accounting applications, as typically acquired in 0-2 years of acute hospital patient accounting positions
  • Experience participating in Payer-specific (Medicare, MediCal, Medicaid, and/or Private) Claims standards, processes, policies, procedures and service level agreements
  • Experience in complex regional/ shared service environment with multiple/ matrix reporting relationships desired
  • In-depth knowledge of various insurance documentation requirements, the patient accounting system, and various data entry codes to ensure proper service documentation and billing of the patient's account
  • In-depth knowledge of Revenue Cycle applications, including Hospital Patient Accounting
  • Data entry skills (minimum 50-60 accurate keystrokes per minute)
  • Ability to communicate and work with patients, physicians, associates, Sutter Health leadership, multiple direct patient care providers and others in order to expedite the patient accounting process. Strong communication skills (verbal and written) in dealing with trainees, associates, and internal/external customers
  • Excellent ability to identify, prioritize, resolve and / or escalate complex problems promptly
  • Ability to learn new applications/software systems effectively and efficiently

Claims Team Lead-sutter Shared Services Resume Examples & Samples

  • Demonstrated leadership experience and a proven track record in Payer-specific (Medicare, MediCal, Medicaid, and/or Private) Claims management in a facility of significant size and complexity, hospital business operations, information systems, and patient accounting applications, as typically acquired in 3-6 years of acute hospital CBO management positions
  • Experience developing Payer-specific (Medicare, MediCal, Medicaid, and/or Private) Claim standards, processes, policies, procedures and service level agreements
  • Experience participating in planning new or expanded services and managing projects desired
  • Deep familiarity with general hospital management principles, practices, and procedures
  • In-depth knowledge/ awareness of all areas related to Payer-specific (Medicare, MediCal, Medicaid, and/or Private) Claims and how they interrelate
  • In-depth knowledge of advanced principles, methods, and techniques related to compliant healthcare billing/collections
  • A comprehensive knowledge of Payer-specific (Medicare, MediCal, Medicaid, and/or Private) Claims management functions in acute and non-acute settings
  • Familiarity with work standards and productivity measures, quality control mechanisms, and workload distribution
  • Knowledge of technological advancements, labor savings procedures/ processes/ equipment and other state-of-the art department-specific systems
  • Knowledge of Patient Management information system applications, preferably EPIC
  • Ability to execute strategy and communicate knowledge of business processes and enabling technologies, specifically in a Payer-specific (Medicare, MediCal, Medicaid, and/or Private) Claims function
  • Ability to serve as a reference and coach others on key Payer-specific (Medicare, MediCal, Medicaid, and/or Private) Claims processes, policies, and procedures
  • Ability to independently set and organize own work priorities for self and for the assigned team, and successfully adapt to new priorities as part of a changing environment. Must be able to work concurrently on a variety of tasks/projects while leading a high volume, high accuracy work team composed of individuals having diverse personalities and work styles
  • Ability to handle heavy workloads and short deadlines in a positive manner. Adapts quickly to changing conditions, assimilating new processes into job functions and taking ownership
  • Excellent ability to establish, develop and manage customer relationships
  • Demonstrated leadership skills and the ability to provide supervision, direction, and constructive feedback to team members to support continuous improvement
  • Ability to effectively detect, surface and resolve conflicts among individuals and/or work groups
  • Ability to communicate ideas both verbally and in writing to influence others using on-on-one contact and group discussions
  • Ability to positively influence others in a desired direction to achieve identified outcomes
  • Ability to develop effective working relationships/ networks within and outside the organization

Senior Manager, Casualty Claims Resume Examples & Samples

  • Manage EPL claims brought against Marriott, including attorney letters, administrative agency charges, arbitrations, mediations and judicial actions
  • Administer Marriott’s global Fidelity insurance policy and manage claims brought under this policy
  • Receive, review and make insurance coverage decisions for EPL and Fidelity claims
  • Conduct initial and follow-up investigations on EPL claims, including attorney demand letters, arbitrations and third-party guest claims
  • Assign EPL claims to outside counsel and negotiate staffing and bill rates
  • Oversee outside counsel through every stage of the litigation process to ensure compliance with Marriott policy, appropriate defense tactics and cost containment
  • Monitor, review and pay invoices and expenses submitted by defense counsel
  • Collaborate with Marriott associates in other departments, including Human Resources, Employee and Labor Relations, Loss Prevention, Internal Investigations, Legal and Internal Audit, in the resolution of EPLI and Fidelity claims
  • Advise the Director of Specialty Claims of any high exposure claims and trends and collaborate on resolution strategy
  • Attend deposition preparation sessions, depositions, arbitrations, mediations and trials
  • Provide knowledge and insight to Human Resource representatives, General Managers and Directors of Finance about Marriott’s EPLI and Fidelity insurance policies
  • Act as a liaison between the field, Corporate and outside counsel to insure that all of Marriott’s policies and practices are applied uniformly and consistently
  • Draft and assist with the review of internal EPL team practices and procedures
  • Attend meetings, conferences and training sessions on topics pertinent to EPL/Fidelity claims handling and resolution
  • Minimum of at least 5 years EPL claims handling experience or related work experience
  • Good communication skills (verbal, listening, writing), including the ability to deliver difficult messages to internal and external customers, outside defense counsel and/or claimants
  • Keen ability to grasp and apply technical knowledge, including litigation case management and disposition oriented claims handling
  • Ability to handle an active list of EPL and Fidelity claims and prioritize work
  • Zealous negotiation and claims resolution skills
  • Strong organization skills and ability to meet deadlines
  • Ability to work well in a team and provide assistance to fellow associates
  • Willingness to accept and respond positively to constructive criticism
  • Ability to present oneself with a positive, professional demeanor
  • Trustworthy with strong business integrity and ability to hold sensitive information in confidence
  • Highly organized and able to handle multiple priorities at any given point in time

Ads-gap Claims Processing Resume Examples & Samples

  • Receives incoming calls to open new claims and obtain documentation and information for claim processing
  • Maintains positive customer relationships in a courteous and professional demeanor in all dealings with the public and fellow employees
  • Accurately identifies and indexes separate documents
  • Accurately inputs data and information in a timely manner
  • Provides consumers, lenders and other partners status of claim and required information and documentation to complete claim processing, including deadlines
  • Ensures consumer understanding of claim process and required documentation including deadlines
  • Provides advanced knowledge of the product and claims processing system which requires specific actions and abilities to communicate effectively with consumers, lenders and other partners
  • Communicates verbally and in written form with our customers, lenders and other parties regarding the adjudication of claims
  • Acts as SME regarding all functionality within the specific AOR
  • Builds and maintains strong working relationships with peers; both internal and external to the AOR
  • Supports Commitment to Communication by participating and advocating any needs or changes
  • Ability to adapt to a constantly changing extremely fast paced environment
  • Intermediate written and verbal communication skills
  • Abilities with Word
  • Ability to learn new computer programs and department processes
  • Strong communication and conflict resolution skills

Claims Adjudicator Resume Examples & Samples

  • Perform claim adjudication for participants of The Major League Baseball Players Benefit Plan in accordance with plan provisions, regulatory requirements, procedural requirements, and quality requirements
  • Review and adjudicate complex claims requiring research, additional information requests, tracking, and written responses. Process and resolve claims which require rework. Submit information to vendor for medical necessity review
  • Provide customer service to plan participants via incoming phone calls. Researches inquiries and responds to callers within required turnaround times
  • Compile information for stoploss and subrogation claims
  • Assist with additional plan administration functions as needed
  • 2-3 years experience adjudicating health claims preferred
  • Medical terminology and coding familiarity
  • Demonstrated experience with Internet, Outlook, word processing, spreadsheets, and databases utilizing multiple screens
  • Superior customer service, written, and verbal communication skills

Claims Intern Resume Examples & Samples

  • Pursuing a Bachelor’s Degree, Associate’s Degree or Technical Diploma in insurance, business, or a medical-related field
  • Availability to work part time during the school year
  • Strong customer orientation and excellent communication skills; verbal, written, and interpersonal
  • Demonstrated analytical and critical thinking skills
  • Proficiency with Windows, MS Office, and web applications
  • Coursework in medical terminology or human anatomy is a plus
  • Prior work experience in medical/health insurance industry is a plus

Claims Team Lead Resume Examples & Samples

  • Proficient understanding of medical terminology, health conditions, company policy provisions, state-specific regulations regarding licensures and benefits, and time requirements and examination procedures
  • Good general insurance knowledge
  • Knowledge of provider care and billing practices
  • Ability to review and interpret policy contracts, provisions, riders and endorsements
  • Ability to make decisions and easily adapt to change and sell them to others
  • Friendly, professional and empathetic telephone manner in order to effectively resolve problems with policyholders, agents, providers or internal customers
  • Familiarity with PC and software programs
  • Ability to meet departmental audit quality standards
  • Ability to work well with others (team player)
  • Strong sense of customer relations
  • Senior examiner/supervisory experience preferred
  • College degree or some college preferred, or comparable experience
  • CPT, HCPCS, and ICD-9 knowledge
  • Strong understanding of hospital contracts

Claims Advisors Resume Examples & Samples

  • Minimum of 5 GCSE’s or equivalent at grade A-C, including Maths and English
  • The ability to manage a demanding and busy workload
  • Strong communication and rapport building skills with the ability to disseminate technical information in a concise and professional manner
  • Quick to take on-board new information which is technical in nature
  • Analytically minded with the ability to resolve complex queries
  • Excellent numeracy skills and comfortable working with large volumes of data
  • Impeccable attention to detail with a methodical and conscientious approach
  • Able to promote continuous improvement and respond positively to change
  • Previous experience of managing complex claims advantageous (although not essential)

Mgr-liability Claims Resume Examples & Samples

  • Plan, select, train, develop, motivate, lead and manage claims staff
  • Manage litigated claims. Coordinate and consult with Legal counsel in lawsuits against the company
  • Develop, implement and manage effective and efficient processes and procedures for the administration and reporting of claims, associated litigation and related escheatment liability
  • Analyze liability claims data to identify trends; conduct strategic planning to control costs associated with claims
  • Develop, implement and monitor the effectiveness of cost containment programs designed to control costs related to liability claims,
  • Manage and control activities associated with the handling of vehicle liability, general liability and property recovery claims and lawsuits to include investigation, evaluation, reserving, litigation, negotiation, resolution, payment and recovery
  • Ensure all claims and related matters are handled in accordance with legal obligations and in compliance with applicable laws, rules and regulations
  • Evaluate coverage, liability, damages, financial exposure; develop defense and settle strategies; identify sources of indemnification, contribution and/or recovery; approve or negotiate settlements in serious claims and litigation with settlement authority up to $350,000
  • Select, negotiate and contract with and manage the performance of all liability claims administration and cost containment vendors
  • Develop, implement, manage and monitor the effectiveness of controls over reporting, audit tools, administration and payment of claims; respond to various internal and external audits of processes, procedures and controls
  • Perform other assignments (or duties) as required
  • Bachelor’s Degree or four (4) years directly related work experience
  • Five (5) years experience managing bodily injury liability and property damage liability claims and litigation of significant exposure and complexity involving serious injuries
  • Comprehensive knowledge of casualty claims, contract, tort, damages, subrogation, contribution/indemnity and other applicable / related law
  • Comprehensive knowledge of insurance policy provisions, practices, laws and regulations
  • Ability to interpret and apply laws and regulations, determine appropriate courses of action, present solutions and resolve claims
  • Excellent leadership and interpersonal skills
  • Strong verbal and written communication skills including presentation skills and public speaking
  • Excellent analytical, problem solving, negotiation, vendor selection, contracting and organization skills
  • Strong knowledge of statistical claims data and reporting
  • Successful completion of required training programs and all licenses as required
  • Professional designation in claims and/or insurance preferred
  • Experience and ability to use Microsoft Office Software, including but not limited to; Word, Excel, and E-mail

IT Claims Interface Development Intern Resume Examples & Samples

  • Eligibility to work in the US
  • Able to commute daily to Lake Oswego, OR
  • Currently pursuing degree in CS, MIS, CIS, AIS, BIS, IT
  • 0 GPA or above at an accredited 4-year University
  • Working knowledge of MS Word, Excel, PowerPoint
  • Must be able to function with minimal supervision
  • Completed courses: Data Structures, Algorithms, distributed computing, Data management, mobile technologies, Java, Math
  • Basic understanding of any Software Development Life Cycle Methodologies (ex. Waterfall and/or Agile)
  • Unix, UI frameworks, SQL knowledge
  • Candidate is interested in working alongside Health Care IT developers and Project Managers in the Information Technology profession
  • Effective presentation and Group discussion Skills

Claims Processing Manager Resume Examples & Samples

  • Works on issues of diverse scope
  • Receives assignments as objectives and determines how to use resources to meet these goals and schedules
  • Requires significant planning and direction setting to coordinate with other divisions or resources
  • Recommends changes to policies and establishes procedures that affect the immediate function
  • Monitors projects to ensure completion on schedule and within budget
  • Minimum three (3) years of lead or supervisory experience in a claims processing environment
  • Experience in LMP environment managing large groups of employees in a collaborative work team environment required
  • Five (5) years of management experience

Claims Adjudicator, Grade Resume Examples & Samples

  • Reviews claims and makes payment determination with authorization limit to a specific dollar limit (ie. $19,999/claim.)
  • Checks with Lead and Supervisor for any claim exceeding specific dollar threshold (ie. $19,999)
  • Reviews and evaluates claims for proper and correct information including, correct member, provider, authorization, and billing information on which to base payment determination
  • Refers to eligibility, authorization, benefit, and pricing information to determine appropriate course of action (i.e. claim reject / denial, request for additional information, etc.)
  • Conducts research regarding coordination of benefits issues, fraud and abuse, and third party liability
  • Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but not limited to CMS, DMHC, DOC, DHS and requirements of accrediting agencies such as NCQA
  • Prepares material for audits and provides assistance to Lead and Supervisor during audit
  • Assists with the preparation of materials for audits (including Quality, Compliance, and Regulatory audits) and provides assistance to Lead and Supervisor during audit
  • Review member/provider claims by checking provider service contracts and other supporting claims documentation in accordance with service agreements
  • Coordinates payment agreements with providers, working with appropriate MSA and Regional Contracts Department staff
  • Proactively works to ensure claim review is resolved appropriately
  • Three (3) years medical claims adjudication experience
  • Experience in processing multiple types of medical claims and lines of business required (inpatient / outpatient, third party billing, hospital, and professional.)
  • Four (4) years medical claims adjudication experience preferred in processing multiple types of medical claims and lines of business (inpatient / outpatient, third party billing, hospital, and professional
  • Experience with SNF, DME, or Home Care/Hospice Claims processing preferred
  • Excellent skills in communication preferred
  • Medical Terminology Certificate preferred

Claims Benefit Specialist Resume Examples & Samples

  • Evaluate and determine if services are covered under the policy
  • Interpret policy provisions by state and determine benefits payable
  • Determine riders on policy , activate and reimburse
  • Confirm clinical reviews are up-to-date prior to reimbursement
  • Apply and determine elimination period days appropriately
  • Coordinate and apply Medicare and other governmental agency benefits
  • Determine initiation of waiver of premium
  • Proficiency in all Citrix-based applications
  • Candidate must have intermediate knowledge of RLTC claims adjudication processes and procedures
  • Knowledge of inter and intra departmental work flows and procedures
  • Candidate must have working knowledge of company claims transaction
  • Candidate must have working knowledge of company plans, riders and benefits including sound knowledge of LTC contract language
  • Candidate must have the ability to identify complex and non-complex payment transaction
  • Candidate should have working knowledge of CSPP and LifePro payment processing in addition to Promise and Beacon

Specialist, Absence Claims Resume Examples & Samples

  • 1 – 3 yrs of experience in insurance claims that directly aligns with the specific responsibilities for this position
  • 1 – 3 yrs of absence management claims experience including familiarity with US Federal and State Leave of Abscense Laws
  • Ability to read, analyze and interpret Short Term Disability documents required
  • Completion of FML certification course required
  • Demonstrated knowledge of medical terminology

Damage Claims Team Lead Resume Examples & Samples

  • Create a claim to track the status
  • Contact parties involved to acquire information about the vehicle’s condition at each point
  • Work with all parties involved to reach a resolution
  • Assist insurance adjuster in settling claim
  • Communicate with parties involved on status and what is needed to proceed with claim
  • Make payment arrangements once settlement is reached
  • Assist others in department as needed
  • Make arrangements for payment to customer and collect payment from vendor
  • Train new employees
  • Track daily emails and faxes received for the team
  • Oversee claims process when manager is out
  • Handle claims for large clients-Toyota, NMAC, Ally, OMSC
  • Provide weekly updates to national accounts on open claims
  • Assist other departments with questions and escalations
  • Resource for team members to seek advice
  • Manage claim rotation spreadsheet
  • Create and maintain documents for departmental training and on-the-job guides
  • Participate in leadership training
  • Distribute new processes to the team and train as needed
  • Perform other duties as directed by department supervisor

Internal Claims Proc Resume Examples & Samples

  • Processes all internal claims or encounters with the exception of DHMO
  • Makes all necessary adjustments associated with the Internal claims or encounter processing
  • Reviews all encounter errors, researches, and tracks required information to resolve errors for submission
  • Reviews and resolves rejected or held internal claims or encounters, taking appropriate actions which may include but are not limited to adjusting, denying, and resubmitting the internal claims or encounters with corrected information
  • Reviews various reports and information to determine the causes of the holds and other issues and resolves by taking appropriate actions
  • Research, proactively work with other departments, and respond to inquiries from internal and /or external customers as appropriate to compile all information gathered to resolve issues promptly and answer any questions in reference to status of internal claims or encounters
  • Applies knowledge of various product types where applicable to help resolve issues
  • Communicate problems and/or trends to management
  • Perform other department duties and special projects as assigned
  • Follows established Code of Conduct for claims processing procedures in compliance with all applicable State and Federal regulations and demonstrates the ability to exercise diligence, care, and integrity in performance of duties
  • Consistently supports Compliance and the KP Principles of Responsibility by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal, State, and local regulations, accreditation and licensure requirements (if applicable) and Kaiser Permanente's policies and procedures
  • Minimum one (1) year of medical claims processing experience

Group Claims Policy Manager Resume Examples & Samples

  • Demonstrated experience in financial services
  • Demonstrated experience in research and innovation and development of new solutions
  • Extensive technical expertise in group and life insurance claims management demonstrated through previous technical and/or leadership roles
  • Development of claims management philosophy and policy
  • Experience in leading change across Customer, Product, Underwriting or Claims
  • Experience in prior leadership positions in Group Claims management will be highly regarded
  • Relevant tertiary qualifications supplemented by relevant work experience

French Claims Resume Examples & Samples

  • Fluent in French and English (spoken, written)
  • Willingness to work at least 1 weekend day and outside of the "standard" work day as needed to support customers, this may include mandatory overtime during peak volume periods
  • Ability to compose a grammatically correct, concise and accurate written response
  • Demonstrate flexibility to work overtime hours as per business requirement
  • Previous data analystical experience including use of SQL, OBIEE or ETL
  • Experience working in a fraud/risk based environment
  • Prior knowledge of the anti-money laundering risk mitigations procedures

Japanese Claims Resume Examples & Samples

  • Fluent in Japanese and English (spoken, written)
  • Willingness to work on weekends, and outside of the "standard" work day
  • Experience with Microsoft Office, including Outlook, Word, and Excel
  • Experience with customer service and/or finance related work
  • Data analysis using SQL, OBIEE or ETL
  • Interpersonal skills, with the ability to communicate complex transactional issues correctly and clearly to both internal and external customers
  • Self-disciplined, diligent, proactive and detail oriented
  • Demonstrated analytical and problem solving skills, including the ability to recognize non-obvious patterns

French Claims Investigation Specialist Resume Examples & Samples

  • Fluent in French (reading and writing)
  • Willingness to work on weekends and outside of the "standard" work day
  • Experience with Microsoft Office, including Outlook, Word and Excel
  • Clear, crisp and proactive documentation of operational procedures required to tackle known risk related patterns
  • Demonstrated ability to analyze problems logically
  • Demonstrated positive, results oriented attitude
  • Ability to effectively manage time, and individually prioritize multiple tasks of competing priority
  • Ability to maintain high levels of confidentiality and data security standards

Director of Claims Resume Examples & Samples

  • Oversee daily claims operations of multiple levels of staff & multiple function across one or more business units
  • Lead project management & implementation & Goal initiatives
  • Oversees Health Plan Audits by providing direction & oversight of scheduling, communication, research, results and any corrective actions responses
  • Oversight & Direction on regulatory Audits in addition to any Regulatory Reporting requirements
  • Assists in Regulatory Audits in addition to any Regulatory reporting requirements
  • 5 years of managerial experience in medical claims adjudication or medical claims processing
  • 2 years of experience managing budgets, process improvements & quality assurance
  • Certified Professional Coder (CPC)
  • 2 years of experience developing presentations to include charting
  • 2 years of experience managing relationships with clients / vendors

Manager of Claims Liability Resume Examples & Samples

  • Current state licensure (RN), baccalaureate degree (preferably in health care)
  • CPHQ preferred
  • 5 years experience in health care and 2 years experience in clinical risk management preferred
  • The capacity and interpersonal skills to successfully interact with hospital personnel and physicians
  • Analytical and statistical skills and broad range of knowledge in healthcare regulatory and accreditation requirements

Senior Claims Developer Resume Examples & Samples

  • Implement claim payment processes that meet regulatory requirements and claim business rules
  • Conduct claims systems utilization, capacity analysis/planning and reporting, and claims-related business and systems analysis
  • Ensure data integrity, data security and process optimization
  • Serve as our internal Regulatory Affairs' point of contact
  • Partner with functional area leaders and SMEs to determine impact and solutions
  • Implement Claim ops solutions to meet regulatory requirements
  • Lead Claim Ops market conduct or financial exam activity, corrective action plans responses and restitution projects
  • Remediate gaps in existing production processes that do not meet regulatory requirements
  • To be considered for a telecommuting role, you must live within 50 miles of a UHG office
  • 1+ year of Visual Basic (VBA) Programming experience
  • 1+ year of VB.NET Programming experience
  • C# programming experience
  • 2+ years of strong Microsoft Excel experience
  • Macro Express Programming experience
  • UNET and /or COSMOS Claims experience
  • Development Planning experience
  • 1+ year of UHC or Optum Claims experience

Claims Policy Resume Examples & Samples

  • Interprets AHCCCS policies, rules and regulations, research changes and additions, identify potential issues, communicate impact of changes to division/agency management, and write/update policies regarding claims payment. Represents Claims Department on committees and in meetings when these concerns arise
  • Provides professional and technical assistance to, and consult with providers, agencies, contractors, other State agencies, CMS representatives, other divisions and staff regarding AHCCCS benefits and reimbursement policy and procedures. Responsible for development, interpretation, communication, writing and updating of claims policy for internal and external customers
  • Works closely with the Claims subsystem issues when identified on audit and training
  • Conducts audits on fee for service providers and is responsible to recoup dollars when claims billed are out of compliance with existing policy and/or billing guidelines
  • Oversight of the staff who develop technical assistance training for AHCCCS Division of Fee For Service (DFSM) Providers. Data research and surveys are used to identify issues affecting providers, which are then addressed through technical training. Oversees the proactive development of education and training to simplify and clarify the technical aspects of claims processing for providers and internal staff
  • This position is also responsible for representing DFSM at administrative hearings and the payment of DFSM claims grieved through the AHCCCS Office of Administrative Legal Services
  • Excellent written and oral communication/presentation skills, business and technical writing techniques, as well as effective interpersonal and group skills
  • Leadership, management, and supervisory experience
  • Principles and practices of claims auditing, as well as Claims and coding submission practices
  • Research, analysis and project management techniques, as well as instruction and evaluation methodologies
  • Analytical and comprehension skills to interpret and apply federal and State statutes and regulations
  • Experience in writing issue papers, interpreting laws and rules, writing decisions and policies
  • Experience in project management and supervision
  • Experience in medical claims and health care delivery systems

Claims Adjudicator Resume Examples & Samples

  • Processing of high priority Claims Financial transactions involving identification and closing of policies, freezing of assets and notification to Beneficiaries of settlement requirements
  • Processing settlements and disbursement of assets according to beneficiaries’ options
  • Identification of transactions that need to be forwarded back to the Business Unit and/or to other departments/teams
  • Referring transactions to Business Unit Support for clarification of handling
  • Reporting processes that need to be included in the team’s online manual to ensure complete process documentation
  • Manage Rush inbox for rush request
  • Investigate, evaluate and settle claims, applying technical knowledge and analytical skills which in effect does have
  • Fair and prompt disposal of cases and to contribute to a reduced loss ratio
  • Payment of claims once all IGO paperwork is received
  • Perform work coordination task for priority task assignments
  • Perform call task (inbound and/or outbound) in order to facilitate completion of death claims processing
  • Computer literate - ability to use the desktop computer system. Advance knowledge on MS application like Word and Excel
  • Ability to use the phone system
  • Follows simple instructions on how to log in to the phone system
  • Basic telephony skills
  • Excellent written and verbal communication skills. Ability to converse effectively using the English language
  • Ability to compose a grammatically correct, clear and concise paragraph/ essay
  • Exhibits good navigation skills
  • Ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems
  • Ability to recommend means of obtaining and analyzing transactional data, as well as evaluate the accuracy of business transactions in accordance with company procedures and contracts
  • Ability to work independently and remain self-motivated with minimal direct supervision
  • Strong organization skills and close attention to detail
  • Good interpersonal skills with ability to interview individuals associated with audit subject matter, as well as communicate findings to management
  • Superior understanding of claims functions
  • Ability to identify business process improvements and report existing deficiencies to management
  • Ability to analyze and manipulate large volumes of transaction-level detail

Claims Go-to-market & Change Navigation Expert Resume Examples & Samples

  • Bachelor’s degree in communications, business or related field
  • MBA and/or other advanced degree a plus
  • 5-7 years business experience, including experience in medium to high complexity change management activities
  • Extensive knowledge of product delivery and adoption tactics
  • Extensive knowledge of change management principles, methods, tools and templates
  • Significant experience delivering new products/services/capabilities and owning benefit realization
  • Significant experience implementing and developing communications and change management plans
  • Highly advanced written communications, verbal communications and interpersonal skills
  • Advanced project management and organizational skills
  • Stakeholder management, including experience interviewing stakeholders and conducting focus groups

REO Claims Senior Rep Resume Examples & Samples

  • Minimum two years mortgage or banking industry experience required
  • Real Estate Owned claims experience preferred
  • Knowledge of Servicing Systems LPS / MSP preferred
  • Proficient with Microsoft Office Products, including Word, Excel, Powerpoint, etc

Claims Director Resume Examples & Samples

  • Provide strategic leadership and technical expertise to the claim organization to achieve profitable growth and customer service goals
  • Effectively lead and drive initiatives to achieve operational excellence and a Best in Class claim organization
  • Bachelor's degree or equivalent required and 10+ years of relevant work experience
  • This position requires proven leadership experience (direct leadership/management experience with formal direct reports strongly preferred)
  • Broad knowledge of Disability products, philosophies, processes and markets, as well as product marketing and distribution is strongly preferred
  • Requires strong team building skills and the ability to build/maintain effective working relationships
  • Must be results oriented with strong financial accumen and the ability to think strategically
  • Excellent management, analytical, problem solving and negotiation skills required
  • Must be flexible and demonstrate good judgement
  • Minimal travel is required

Claims Generation Team Lead Resume Examples & Samples

  • Experience managing a small team of 15 employees
  • Medical claims billing experience
  • Familiar with payer requirements of claims, such as insurance guidelines, modifiers and HCPC codes
  • Payroll Experience
  • DME Industry Experience

Claims Senior Service Specialist Resume Examples & Samples

  • Activities are of moderate complexity, requiring some independent judgment, performed under general supervision, using procedures standard to the organization
  • Demonstrates knowledge of internal operations and develops relationships to facilitate workflow
  • Knowledge of Excel, Word and PowerPoint, a plus
  • Experience in working independently in a face paced environment

Claims Adjudicator Resume Examples & Samples

  • Analyzes data feeds from carrier commission statements to substantiate customer reimbursement requests
  • Evaluates customer manual claims submissions against employer plan rules and IRS 213(d) guidelines
  • Compiles weekly reports for TPA Leader comprised of approved and denied claims
  • Coordinates distribution of claims denial letters
  • Assists TPA Leader with internal and external audits
  • High School diploma required; 4 year college degree preferred
  • 1 year experience in customer service required. 2-3 preferred. Experience in retiree HRA industry highly preferred
  • Demonstrated mathematics skills
  • Must understand reimbursement rules for qualified health expenses
  • Able to provide the highest level of attention to detail to ensure accuracy

Total Loss Claims Senior Service Specialist Resume Examples & Samples

  • Performing support functions including email, calendar management, and word processing with a strong emphasis in excel
  • Processing total loss claim files and payments
  • Receiving, screens and routing incoming telephone calls and other electronic correspondence
  • Generating and sending appropriate forms to insured/claimant for completion
  • Completing all necessary forms, logging documents into the system, and route documents to the appropriate parties

Debit Card Claims Reg E Specialist Resume Examples & Samples

  • Carries out specialized research to resolve problems
  • Helps train personnel in the department
  • Monitors laws and regulations to ensure compliance
  • Maintains forecasted production to meet departmental goals
  • Investigate a minimum of 80 Checkcard claims per day
  • Review Dispute Forms and Regions systems to identify fraudulent activity and validity of customer's claims
  • Adhere to Regulations - E time frames in completing investigations
  • Communicate with customers regarding claim resolution per regulatory requirements
  • Review claims for chargeback rights based on transaction type and provide appropriate documentation to Chargeback Dispute Analyst for initiation of funds recovery

Senior Ba-claims Resume Examples & Samples

  • Senior Business Analyst
  • Business Focused Role
  • 6 Month contract with a view to extend!
  • Claims

Director of Claims & Appeals Resume Examples & Samples

  • Develops and executes strategies for a function or discipline that span a large business unit or multiple markets / sites
  • Directs others to resolve business problems that affect multiple functions or disciplines
  • Product, service or process decisions are most likely to impact multiple functions and/or customer accounts (internal or external)
  • Ensure that proper benefits are applied to every claim
  • Identify and apply knowledge of new plans / customers to process their claims appropriately
  • Identify and resolve claims processing errors / issues and trends, as needed (e.g., related to system configuration, network, eligibility, data accuracy, vendor-related, provider)
  • Resolve or address new or unusual claims errors / issues as they arise, applying appropriate knowledge or prior experience
  • Communicate and collaborate with external stakeholders (e.g., members, family members, providers, vendors) to resolve claims, errors / issues, using clear, simple language to ensure understanding
  • Collaborate with internal business partners to resolve claims errors/issues (e.g., Subject Matter Experts, Network Management, IT / systems staff, Compliance, vendor management teams, contract teams)
  • Document and communicate status of claims / investigations to stakeholders as needed, adhering to reporting requirements (e.g.,status letters / reports)
  • Communicate the value of our products and services to applicable audiences, using clear, simple language to ensure understanding
  • Identify and communicate opportunities to improve claims processing efficiency and reduce rework (e.g., workflows, knowledge / process gaps, customer needs, claims volumes / submissions, issues related to quality / resources / systems, automation opportunities)
  • Provide advice / consulting / direction / support to colleagues as needed to enhance their ability to process claims accurately
  • Identify training opportunities among peers and / or staff members
  • 10+ years of Leadership Experience
  • 5+ years of experience in Claims, Grievances and Appeals

Claims Adjudicator Resume Examples & Samples

  • Claims Processing
  • Reviews claim requests to determine eligibility for processing and escalate to management as necessary
  • Makes appropriate system entries and verifies accuracy
  • Ensures utilization of most up to date processes and procedures to update claims
  • Identifies process improvements, offers solutions to claim problems, and communicates recommendations to management
  • Manages tasks according to company guidelines
  • Client Inquiries
  • Responds within company standards to inquiries by telephone and written communication
  • Works with colleagues across the organization to research inquiries in a prompt, courteous, and accurate manner
  • Claims processing and/or medical office experience preferred. No claims experience required
  • Excellent written and verbal communication skills to effectively interact with customers on the telephone
  • Excellent organizational and time-management skills to handle multiple tasks
  • Basic computer skills and the ability to navigate through multiple systems without assistance

Claims Approver Resume Examples & Samples

  • Reviews, processes and pays claims on death, cancer, ordinary/industrial accident and health, and total and permanent disability according to Company procedures and appropriate state regulations
  • Determines proper payees for payment to assure that the Company is fully discharged from liabilities associated with claims
  • Identifies claims that meet qualifications for payment via Life Accounts, and completes processing necessary to set up the accounts
  • Enters claims into systems, maintains pending files, matches output to the appropriate file and distributes new mail
  • Handles incoming calls from policyholders, insureds and other external or internal customers promptly and professionally
  • Audits paid claims for accuracy and completeness. Verifies that all needed information was received and codes statistical data regarding cause of death as required
  • Experience in maintaining a high degree of accuracy associated with high volumes of work and/or multiple duties. Ability to continuously make repetitive motions of the wrists, hands and/or fingers
  • Demonstrated experience maintaining the confidentiality of information handled in the course of completing work
  • Proven experience working in a customer-oriented field and effectively articulating information to clients in a patient and understanding manner while managing multiple tasks
  • Proven strong analytical skills, including demonstrated experience identifying and quantifying problems and providing effective resolutions when dealing with multiple alternatives
  • Demonstrated experience working effectively within a team. Must provide examples from work experience of going above and beyond the call of duty to assist team members
  • Must provide examples of working under multiple deadlines and minimal supervision. Must be able to cite examples of self-motivation and effectively completing work when given little or no direction
  • Demonstrated excellent verbal and written communication skills with the ability to successfully interpret and communicate business needs to internal or external customers in a clear, focused and concise manner while following proper rules of punctuation, dictation and style. This would include strong telephone communication and etiquette skills
  • Proven experience adapting and demonstrating flexibility associated with changes to policies/procedures
  • Demonstrated experience acquiring and assimilating new knowledge and skills. Must be able to cite examples of work experience wherein new skills were applied to successfully complete assigned tasks
  • Working knowledge of word processing, spreadsheet and Microsoft office applications

Claims Resume Examples & Samples

  • Willingness to work on weekends, and outside of the "standard" work day, work overtime during peak periods as needed
  • Ability to write clear, crisp and proactive documentation of operational procedures required to tackle known risk related patterns
  • Proven ability to work in fast paced dynamic environments where decisions are made without compromising on customer experience and financial losses
  • Contribute to or lead other special projects which support reducing risk related losses while maintaining focus on positive customer experience
  • Maintain individual accountability for performance metrics, ensuring ever-increasing levels of productivity and accuracy against established benchmarks
  • Identify, communicate, and champion process improvement opportunities that will benefit internal and external customers
  • Demonstrated ability to work independently and make complex investigation decisions with little to no guidance
  • Self-disciplined, diligent, proactive, and detail-oriented
  • Proven ability to work in fast-paced dynamic environments where decisions are made without compromising on customer experience and financial losses and maintain high levels of confidentiality with data security standards
  • Excellent team player capable of learning and sharing knowledge in a global team environment
  • Experience with service launches / system testing / program management
  • Experience with ticketing system, deep dives or escalations work in customer service
  • Demonstrated ability to analyze problems logically utilizing data queries pulled from SQL, OBIEE and ETL
  • Experience in e-commerce fraud operations
  • Previous experience leading others, coaching, recruiting and training employees

Claims Adjustor Resume Examples & Samples

  • Daily receipt, review and coding of new claims for entry/update in the internal claims software system and from Customer Service call center. Initial telephone contact to be completed within 24 hours of receipt of new claims
  • Management of non-litigated claims to include investigation, management of chargeback process, determination of Medicare eligibility, resolution of any conditional payments and investigation into the need for an MSA, liability evaluation and settlement in accordance with General Liability Claims Handling Guidelines. Routine communication with store and regional team members, customers and/or legal representative via routine phone calls and written correspondence. Obtain, review and evaluate medical bills, records and/or damage estimates
  • Maintain routine diary with minimum goal of 90% compliance at each diary review (30 – 45 days) per adjustor guidelines, to include but not limited to
  • Documentation of initial 24 hour telephone contact
  • Documentation of all conversations and evaluations in notes
  • Documentation of reserves and rationale for amount
  • Documentation of Medicare eligibility and Conditional Payment research
  • Documentation of reserve/settlement authority
  • Daily documentation of all contacts/required actions /status related to claim
  • Contracts/invoices/leases related to claim
  • Work with insurance carriers and third party contractors for acceptance to tender based upon contractual liability and obtain written acceptance, or subrogate claims that we settled on behalf of a vendor or other third party contractor
  • Responsible for managing chargeback program for assigned claims including updates in system documenting charges to stores for incidents and making timely reversals per Asset Protection’s chargeback SOPs. This includes monthly review of all charged and non-charged claims reporting changes which will appear in the store’s monthly P&L statements
  • 3-5 years of GENERAL LIABILITY claims handling and/or customer service experience
  • Bachelor degree in Business or Risk Management preferred
  • Ability to work independently within reserve authority and provide recommendations for claims over authority to present to Litigation Specialist or GL Claims Supervisor
  • Knowledge of civil torts to provide liability and damage evaluations (to negotiate claims with customers and/or their attorneys)
  • Ability to review contracts and understand insurance obligations for risk transfer
  • Experience working with multiple jurisdictions
  • Proficient in the use of a claims software system and Microsoft Office applications
  • Ability to work 9am to 6pm

IT Lead-claims & Toxicology Resume Examples & Samples

  • Partner with the business partners to manage the overall IT demand & continously manage business partner expectations
  • Prepare and deliver regular updates and communications (verbal and written) to the Business and IT Leadership teams, and extended business partners
  • Understand and define business drivers, requirements definition, design gap analysis, prototyping, execution and deployment activities
  • Function as a technical application owner (TAO) for the existing technologies and applications that support this function and ensure business partners are aware of new and emerging technologies in the Open Innovation, Business Development, Business Process Management, and UX/Digital Design
  • Conduct research on current / future technologies, processes and best practices, benchmark with other internal J&J companies and external partners, and determine application of new technologies in the Consumer Companies R&D organization
  • Lead projects of medium complexity, and act as Liaison between the various IT organizations to ensure successful delivery of initiatives to the business partners
  • Lead efforts to standardize processes and technologies globally
  • Champion the change management efforts of IT initiatives with the business partner community
  • Interface with suppliers and vendors to evaluate software, hardware, or services and make recommendations
  • Ensure Service Level Agreements are established and meet expectations of the business partners
  • Perform analysis, design, implementation, and maintenance activities
  • Actively participate as core team member for key business/IT initiatives
  • Participate in the business planning activities by identifying future business demand and ensuring appropriate funding is in the business plan
  • Provide coaching/guidance to peers, junior team members, co-ops and/or consultants
  • Consistently demonstrate knowledge seeking and sharing behaviors across IT organizational boundaries in the performance of daily work and encourage junior associates to do the same
  • Apply principles, concepts, and practices of the J&J Leadership Imperatives
  • Ensure that J&J information assets are appropriately identified and valued, and are protected by complying with and enforcing all local and worldwide security policies
  • Ensure that security is considered and emphasized in all IT plans and actions
  • A minimum of a bachelor's degree is required
  • A minimum of 5 years of IT experience is required
  • Hands-on experience supporting R&D groups is preferred
  • Hands-on disciplined project management skills are required
  • Hands-on experience in one or more of the following Cloud / SAAS / Mobile models is preferred
  • Hands-on experience with one or more of the following webMethods / IMDG / BPM is preferred
  • Broad understanding of Design Principles (User Interface and Business Process Mapping) is preferred
  • A demonstrated working knowledge of core application development principles and J&J SDLC methodology is preferred
  • Demonstrated ability to lead a team and manage work in accordance with full system lifecycle (SDLC) from concept to production deployment is preferred
  • Hands-on experience supporting an application portfolio (post-launch) is required
  • Experience implementing global process/systems is preferred.Info Technology

Manager, LTC Claims Contact Center Resume Examples & Samples

  • Responsible for supervising the efficient, professional and timely processing of all claims related items as well as the opening of new claims
  • Take customer escalations and ensure appropriate follow up
  • Train staff in system and departmental procedures. Oversee the development and updating of operating procedures and training manuals. Develop and conduct individual and group training sessions
  • Ensure efficient organization in staff scheduling to accommodate call volume, coverage hours and unexpected absences
  • Participate in the creation and maintenance of individual and department metrics
  • Increase department productivity with continual monitoring and measuring of performance levels and QA standards
  • Participate in development and management of call 'scripts' and ensure they're adhered to
  • Maintain current department reports and work with the leadership and workforce teams to develop new ones to increase department productivity and profitability
  • Use Contact Center systems, including call management and recording system
  • Lead, coach and motivate team members
  • Provide regular feedback and direction to associates regarding team and personal performance. Take corrective action as necessary
  • Write and deliver performance evaluations and participate in salary planning
  • 3-5 years training and coaching experience
  • Ability to work independently and in a matrix organization
  • Ability to maintain confidentiality of customer and employee information
  • Experience in a similar leadership role with an insurance or financial services company
  • Prior success in a role as a contact center team leader, trainer or supervisor
  • Experience developing training materials, documenting processes, and interpreting contract language and/or procedures
  • Medical experience, worked with the elderly or understanding of long-term care industry helpful

FCD Claims Phones Resume Examples & Samples

  • Minimum of 2 years of management experience strongly preferred(Internal or External)
  • Influence without authority: Negotiate to win/win outcomes & Influence others to work collaboratively on common goals
  • Risk and Controls mindset: Wears the Risk and Controls hat to ensure employees know the policies and procedures that govern their work and duly adhere to it. Is able to identify key gaps/opportunities that could potentially pose as a threat/risk to our company and help remediate these issues effectively. Abides by all applicable regulatory requirements
  • Do the right thing: Is able to maintain the highest standards of integrity by doing the right thing for our customers, our employees, our shareholders and all our partners

Claims Advisors Resume Examples & Samples

  • Previous claims handling experience advantageous, although not essential
  • Sound numeracy skills and comfortable working with large volumes of data
  • 5 GCSE’s at A-C grade (including Maths and English) desirable (or equivalent experience)

Cres REO / Claims Proc Senior Resume Examples & Samples

  • Reviews and analyzes more complex claims and takes appropriate action
  • Evaluates, processes, and monitors mortgage loan foreclosure/workout claims from the date of filing to the date funds are received when a foreclosure or loss mitigation action has been completed
  • Reviews Consumer Finance Department foreclosure, First Hawaiian Bank and SBO foreclosure requests. Communicates with the requestor marketing views and/or opinions for the approval or denial of the requests
  • Communicates directly with the claims outsource vendor, the real estate management company and SBO companies to ensure timely filing, monitors file during eviction, discusses marketing strategies, resolves outstanding problems, and facilitates the sale of each property
  • Approves initial and subsequent repair requests and negotiates purchase offers within guidelines
  • Ensures that each OREO loan carries a proper book balance and adjusts the balance accordingly by processing appropriate accounting entries
  • Controls losses by resolving problems, analyzing timelines, providing reasons for delays, and documenting unusual circumstances to obtain maximum claim reimbursement
  • Makes recommendations to management outside of guidelines
  • Completes functions within established policies, procedures and regulations for four different types of insurers and any investors, if applicable
  • Completes monthly OREO status report with current updates of each property along with reconciliations of accounting entries made, adjusting OREO book balances to the total general ledger amount. Also provides monthly reporting on foreclosure, marketing and sold status of SBO loans
  • Prepares all final OREO dispositions and journals when properties are sold. Closes out claim file by auditing claim for any supplemental claim filings and closing claim loans when final funds are received
  • Provides customers and other departments with information for OREO properties
  • Assists with the training of other department employees
  • Years of functional/professional experience: One+ years of experience in mortgage loan servicing
  • One+ year of experience in real estate/property management
  • Good knowledge of mortgage documents and mortgage servicing procedures
  • Good knowledge of collections/foreclosure/bankruptcy procedures
  • Thorough understanding of all mortgage loan claim requirements
  • Knowledge of MS Office software, including Word, Excel, Outlook and Windows
  • Ability to meet deadlines and time parameters
  • Customer service and interpersonal skills

Group STD Claims Case Manager Resume Examples & Samples

  • Communication (Verbal and Written)
  • Strong math aptitude skills
  • Regulatory and Compliance experience a plus
  • Minimum 2 years of disability claim management experience (STD preferred), or other previous Group insurance experience

FML Claims Case Manager Resume Examples & Samples

  • FMLA and Group Disability claim experience or group benefit product knowledge strongly preferred
  • Strong interpersonal and PC skills (e.g., Microsoft Word & Excel)
  • Minimum 1-2 years experience working with group disability or absence management, medical disability services or similar preferred; knowledgeable of governing regulations and medical terminology
  • Previous case management, customer service or call center experience desired

Director of Claims Resume Examples & Samples

  • Investigate, evaluate and dispose of high exposure, complex medical malpractice and general liability claims
  • Oversee the operational and technical work of the claims team and implement claim