Claims Specialist Resume Samples

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KH
K Halvorson
Kody
Halvorson
222 Myrna Valley
Chicago
IL
+1 (555) 886 9539
222 Myrna Valley
Chicago
IL
Phone
p +1 (555) 886 9539
Experience Experience
New York, NY
Claims Specialist
New York, NY
Pouros, Lubowitz and Gleichner
New York, NY
Claims Specialist
  • Researching and providing technical assistance to contracted service providers, Division staff and other external entities relating to claims processing
  • Assemble data, analyze performance, identify problems and develop recommendations to support Project Management planning and operations
  • Develop a professional working relationship with the Client, on-site field investigators, technicians, management team and other personnel
  • Support Claims Management in establishing departmental objectives and procedures to provide direction to claims team
  • Performs liaison services to both internal and external customers providing assistance in claims
  • Make outbound calls to carrier, injured employee & health care providers to obtain work status and case notes
  • Performs quality assurance audits APD claims files to measure quality, provide feedback and develop employees
Houston, TX
Unemployment Claims Specialist
Houston, TX
Metz-Prohaska
Houston, TX
Unemployment Claims Specialist
  • Good problem solving and decision making abilities
  • Focusing on financial impact of claims and actively pursues opportunities to enhance unemployment results and impact unemployment tax rates
  • Researches partner separations and builds claim responses; ensures the timely, courteous and professional follow up to incoming phone calls, and emails
  • Reviews and updates cases for completion, accuracy, routing and resolution
  • Develops effective working relationships with customers, team members, Starbucks partners, and other Starbucks organizations
  • Effectively manages multiple cases, following up with customers, vendors, etc. to ensure a timely and satisfactory resolution
  • Ensures that work is accurate and complete, processed in a timely manner with proper spelling and grammar
present
Boston, MA
Senior Claims Specialist
Boston, MA
Shields LLC
present
Boston, MA
Senior Claims Specialist
present
  • Provides plan and claim information, assists with submission of claims, and makes outbound calls to gather missing information on incomplete claims
  • Participate in the development of policies and procedures to improve department workflow and the claims process ensuring proper documentation
  • Manage return to work with the Return to Work Coordinator
  • Provides claim information, assists with submission of claims and makes outbound calls to gather missing information on incomplete claims
  • Collaboratively work with a network of approved in-house professionals and monitoring the progress of a claim
  • Advise clients of their claim related obligations under the policy and establish client-specific claims management procedures
  • Monitors and improves the performance of trading partner’s services for your clients
Education Education
Bachelor’s Degree in Integrity
Bachelor’s Degree in Integrity
University of California, Berkeley
Bachelor’s Degree in Integrity
Skills Skills
  • Knowledge of diagnosis and procedure codes, general medical terminology, and disability duration guidelines
  • Strong communication, negotiation and presentation skills. Ability to effectively interact with all levels of CNA's internal and external business partners
  • Manage an inventory of claims to evaluate compensability/liability
  • Detail oriented/ability to follow client specific guidelines
  • Knowledge of all types of professional claims
  • Solid knowledge of claims and insurance theory and practices
  • Strong interpersonal and communication skills. Ability to effectively interact with all levels of CNA’s internal and external business partners
  • Solid knowledge of claims and insurance industry theory and practices
  • Solid knowledge of Microsoft Office Suite as well as other business-related software
  • Knowledgeable in MS Word and MS Excel
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15 Claims Specialist resume templates

1

Life & Specialty Claims Specialist Resume Examples & Samples

  • Minimum 2 years of direct claims experience
  • Working towards an insurance industry designation (at minimum 1 course completed)
  • Experience in effectively managing complex claims
  • Bilingualism in French and English, written and spoken considered an asset
2

Senior Claims Specialist Resume Examples & Samples

  • Evaluate claims, provide support information and recommend authorization decisions to the VP Risk Management
  • Oversee claim data management, principally in a digital environment
  • Performs other assignments and projects as requested
3

Title Claims Specialist Resume Examples & Samples

  • Two to three years of experience in loan processing and closing activities
  • Two to three years of experience applying general accounting principles
  • Strong knowledge of loan processing and closing policies and procedures
  • Well-developed ability to manage multiple tasks/projects and deadlines simultaneously
4

Senior Claims Specialist Resume Examples & Samples

  • 5+years claims experience
  • High School diploma required, degree preferred
  • Ability to create the most complex and successful strategies for risk mitigation
  • Knowledge of claim handling & claim adjudication processes and procedures
  • Understand the basic process and value of basic data analytics and benchmarking
  • Ability to communicate technical information orally and in writing
  • Travel required
5

Claims Specialist Resume Examples & Samples

  • Claims adjudication experience
  • Ability to multi-task Manages time effectively
  • Committed to superior customer servicing
  • Ability to work independently, a self- starter
  • 3 – 5 years claims adjudication experience
  • College preferred, or equivalent work experience
6

Claims Specialist Resume Examples & Samples

  • Review information contained on the initiation system and set up new claims into the claims system according to the terms of the plan purchased
  • Set adequate reserves to ensure proper reporting
  • Verifies travel insurance coverage utilizing various methods e.g., computer, fax, manifest, e-mail or telephone
  • Provide insurance verification of coverage for the assistance companies
  • Mails out appropriate claim forms, letters and related correspondence
  • Cultivates relationships with individuals at tour operators and cruise lines in order to obtain the necessary claim information
  • Assists with incoming electronic correspondence
  • Assists with opening and prepping the daily mail
  • Assists as needed with Scanning documentation and pertinent information to AS400 IMS/21 document system individually or batch mode
  • Liaison with Customer Service and assists with phone calls
  • Assists Claims Examiners with claims adjudication
  • Generates letter requests for the Claims Specialist II
  • Follows up on outstanding medical records requests
  • 2-3 years of work experience in an office environment
  • General office skills including data entry
7

Claims Specialist Resume Examples & Samples

  • 3+ years of directly related industry experience
  • Experience in reading and understanding UB04 and HCFA forms
  • Experience in Workman’s Compensation and Motor Vehicle Claims processing
  • Solid negotiation and analytical skills
8

Claims Specialist Resume Examples & Samples

  • Manages the appropriate level of resources for your clients
  • Displays a visible sign of professionalism and direction for the practice
  • Maintains local relationships with all major trading partners
  • Participates in meetings and provides ideas and strategies that strengthen the practice
  • Ensures quality and consistency in executing best practices
  • Partners with others as necessary to continually improve quality and innovation of group
  • Monitors the performance of trading partner’s services for your clients
  • Ensures practice strategy alignment with Willis business plans
  • Maintains direct relationships with key clients
9

Supplemental Rent Claims Specialist Resume Examples & Samples

  • Logs and initiates all customer claims
  • Reviews customer claim documentation for completeness and works with customers to resolve shortfalls, as necessary
  • Customer’s first point of contact within GECAS for all claim related queries
  • Identify and collate relevant contractual obligations to support maintenance event claims
  • Interpretation of contractual maintenance and AD cost sharing formulae
  • Administer all lessor contributions, including budgetary approval
  • Monitor claims process to ensure cycle time targets are achieved
  • Serves as a focal point for all queries relating to customer claims
  • Undertake claims assessment and reporting to support GECAS sales activity and serviced entity queries
  • Provides on-going analysis and reporting to support other functions and project related work
  • Supports Claim Manager by leading face-to-face customer meetings to plan maintenance, work-scopes and claims
  • Professional Engineering, Financial or Business degree
  • Demonstrated experience in the interpretation of contractual language
  • Experience in and an understanding of work-scope documentation and shop visit reports
  • Demonstrated capability in developing and maintaining good working relationships, at all functional levels, within customer airlines
  • Strong system and computer skills
  • Aviation industry experience
  • Working knowledge of operating lease structures
  • Ability to manage multiple tasks and to prioritise
  • Good communication skills - written and spoken
10

Claims Specialist Resume Examples & Samples

  • Commitment to preserving confidentiality
  • Must be available to work overtime and/or weekends depending on business needs
  • Proficiency in all Microsoft Office Programs, including Word, PowerPoint, Excel, and Access
11

Claims Specialist Resume Examples & Samples

  • Bachelor's Degree in a related field
  • Knowledge of order to cash
  • Knowledge of SAP navigation & logic
12

Senior Claims Specialist Resume Examples & Samples

  • 8-10+ years experience in multi-jurisdictional claims handling or related work with an insurance service provider and/or preferably in a large, multi-location corporation (an insured)
  • General liability claims experience required, preferably for entertainment, sports, hospitality, retail or similar accounts with customer-intensive claims
  • Experience with litigated claims having multiple defendants and complex, 3rd-party contract elements required; must be conversant with legal environment and legal system procedures
  • Analytical skills necessary to obtain and evaluate complex information, analyze problems, develop alternative solutions, and project long-term effects of decisions
  • Ability to effectively prioritize, organize, and perform multiple tasks with strict deadlines
  • Ability to develop relationships and work collaboratively with project teams
  • Strong Microsoft Office skills required; demonstrated competency in Excel
  • Proficiency in commonly used claims information data base systems
  • College degree and/or equivalent experience required
  • Applicable insurance/claims certifications and licenses a plus
13

Unemployment Claims Specialist Resume Examples & Samples

  • Provides coaching and guidance to regional partner resource generalists, district managers, and store managers on the interpretation of Starbucks unemployment, policies and procedures
  • Analyzes and investigates partner separations in consultation with others in Partner Resources, external contacts or other departments outside PRO Solutions & Services
  • Provides strong customer service by effectively managing customer expectations while meeting customer needs
  • Researches partner separations and builds claim responses; ensures the timely, courteous and professional follow up to incoming phone calls, and emails
  • Reviews and updates cases for completion, accuracy, routing and resolution
  • Develops effective working relationships with customers, team members, Starbucks partners, and other Starbucks organizations
  • Effectively manages multiple cases, following up with customers, vendors, etc. to ensure a timely and satisfactory resolution
  • Maintains current knowledge on state to state unemployment processes, Partner Resources policies, procedures and best practices
  • Participates in cross-functional teams to successfully execute programs and projects
  • Performs research and analysis to maintain expertise in specialized state unemployment policies, laws and regulations
  • Customer service (2 years)
  • General human resources (2 years)
  • Case management (2 years)
  • Ability to conduct independent research and analysis
  • Proficient in Microsoft Office Suite (Word, Excel, PowerPoint, Visio, Microsoft Project)
  • Ability to work in a fast-paced and changing environment
  • Ability to work both independently and as a member of a team
  • Knowledge of SAP (production environment) or similar software
14

Contestation / Claims Specialist Resume Examples & Samples

  • Experience with claims adjudication processes and identifying claim overpayment errors for inpatient and outpatient providers
  • Prior experience with claims adjudication processes for a healthcare organization or managed care provider
  • Ability to analyze paid claims and review reports to identify discrepancies for contesting/appealing according to established procedures
  • Ensure correctness of delivery systems, participating providers, and contractual arrangements per market
  • Effective communication verbally and written
  • Experience in analyzing and reporting large volumes of data
  • Microsoft Office using Access, Excel, Word, and Power Point
  • Understanding of Current Procedural Terminology (CPT) codes, ICD- 9CM, ICD-10CM, Ambulatory Surgical Center (ASC) groupers, and Diagnosis Related Groups (DRG) and managed care
  • Knowledge of Centers for Medicare and Medicaid Services (CMS) guidelines
  • Self-motivated creative and analytical background
  • Understanding of multiple health plans claims data files, i.e. Humana service fund reports
  • 5 +plus years of understanding health care claims processes and systems
  • Experience with understanding Medicare and Medicaid Risk models
15

Senior Claims Specialist Resume Examples & Samples

  • Extensive experience of handling claims of a complex nature
  • Helps develop and execute the strategies of the practice - leading full team (including Risk Control Consultant and Data Analyst) on creating strategy for larger accounts
  • Handles complaints, arbitrates disputes and negotiates alternative solutions
  • Consults with clients to help mitigate their risk
  • Support new business with sales presentations and RFP
  • Monitor the performance of trading partner’s services for your clients
  • Ensure appropriate program design and documentation - service scope aligns
16

Claims Specialist Resume Examples & Samples

  • Ensure support for business lines (lab and business) by evaluating and validating communications for products
  • Evaluate regulatory and media risks of claims along with different products communication aids
  • Help identify and report product communication issues
  • Education : Minimum BA or BS
  • Years of working experience : 0 to 3 years
  • Experience : Lab or regulatory experiences
  • Language : English
  • Other skills : Interpersonal skills
17

Claims Specialist Resume Examples & Samples

  • Reconcile claims filed to payments received on Investor and Mortgage insurance claims
  • Prepare claim payment reconciliation to ensure full payment is received
  • Create and update charge removal payments balancing to claims payments received
  • Determine root cause of curtailed items and determine whether supplemental claim, client expense, or loss has been incurred
  • Follow up on claim payment status for unpaid, filed claims
  • Update the system with pending, submitted, withdrawn, and paid claim information
  • Recommend improvements to established procedures and processes
  • Analytical Thinking: The ability to tackle a problem by using a logical, systematic, sequential approach
  • Diagnostic Information Gathering: The ability to identify the information needed to clarify a situation, seek that information from appropriate sources, and use skillful questioning to draw out the information when others are reluctant to disclose it
  • Personal Credibility: Demonstrated concern that one be perceived as responsible, reliable, and trustworthy
  • Stress Management: The ability to keep functioning effectively when under pressure and maintain self control in the face of hostility or provocation
18

Senior Claims Specialist Resume Examples & Samples

  • Coordinate and oversee claims management strategies on reserving, settlement and closure to bring claims to resolution
  • Communicate and go on-site as necessary to all NJ warehouses to assist with all internal claims management activities
  • Participate and manage quarterly claims reviews with the TPA for managed claims
  • Develop and Monitor goals for claim mitigation within stores
  • Manage return to work with the Return to Work Coordinator
  • Act as an internal resource for Workers’ Compensation questions
  • Utilizes TPA RMIS system for claims management
19

Senior Claims Specialist Resume Examples & Samples

  • Help develop and execute the strategies of the practice - leading full team (including Risk Control
  • Consultant and Data Analyst) on creating strategy for larger account
  • Handles complaints, arbitrates disputes, and negotiates alternative solutions
  • Consults with client to help mitigate their WC risk
  • Ensure TPA/Carrier performance through claim reviews, audits, etc
  • 3+years claims experience
  • Degree required
  • Knowledge of workers compensation claim handling & claim adjudication processes and procedures
  • Knowledge of New York State laws, legal codes, procedures and processes involving WC insurance
  • Knowledge of Construction Industry WC claims
20

Claims Specialist Resume Examples & Samples

  • Adjusts property and general liability claims in the snow sports industry
  • Determines coverage; sets and adjusts reserves
  • Oversees all phases of incident investigation; conducts interviews/site inspections; hires outside experts and adjusters
  • Negotiates settlements within authority
  • Hires and directs defense counsel; manages defense budgets; plans and oversees discovery process; attends depositions, hearings, mediations and trials, as necessary
  • Provides risk management services to assigned snow sports accounts
  • Advises insureds on all aspects of ski area operations, claims, settlement negotiations and other risk management and insurance issues
  • Responds immediately to notice of catastrophic losses by traveling to and overseeing the on-scene accident investigation, as necessary
  • Acts as Risk Management resource for insured and snow sports industry
  • Disseminates information through daily contact and periodic visits with insureds
  • Conducts Risk Management seminars; participates in industry related meetings and seminars; conducts periodic on-hill inspections and operational inspections, as assigned
  • Bachelor’s degree and 5-7 years of property and casualty claims adjusting experience, or equivalent combination of education and experience
  • P&C Adjuster's license is required
  • Must be an advanced level skier/snowboarder with own equipment and a passion for the snow sports industry
  • Independent, entrepreneurial spirit
  • Must be committed to client relationship management and service
  • Proficient with computer programs, including Word, Excel, and Outlook
  • Travel, up to 25% of the time, is required. Most travel is planned in advance but some travel is required on an "on call" basis
  • Prior ski resort risk and operations experience a plus
21

Claims Specialist Resume Examples & Samples

  • Execute policies and procedures governing the establishment and management of 3rd Party Liability, Bodily Injury case reserves
  • Proactively monitor legislative and jurisprudence changes and competitor policies and practices
  • Participates in authority committee meetings
  • Alert their manager to any required policies, procedures and product changes based on exposure or risk due to judgements, wording, etc
  • Contribute to a culture that promotes ethical practices and a high degree of integrity
  • Financial Management
  • Acts as a role model in openly endorsing the organization goals and strategies
  • Proactively monitor market changes and competitor offerings, assess current and future client needs and evaluate unit effectiveness in responding to changing conditions
22

Claims Specialist, Complex Casualty Resume Examples & Samples

  • Handles litigated claims as per TDI legal protocol
  • Make recommendations to their manager on trends with respect to legislative and jurisprudence, supplier relationships and the overall book of business
  • Collaborate to ensure sound business relationship for 3rd Party Liability, Bodily Injury with legal services suppliers and meet regularly to optimize knowledge transfer
  • Responsible for identifying and preventing indemnity leakage on files
  • Work closely with other Complex and Specialist Claims Analysts and the actuarial department to examine trends and predictors that may have a financial impact on Bodily Injury case reserves
  • Collaborate with internal and external stakeholders and contribute to the Bodily Injury claims team to accomplish goals and objectives
  • Provide ongoing support and coaching to support the development of Bodily Injury analysts
  • Continuous Improvement
  • Develop and encourage change and innovation at all levels of the unit and foster continuous improvement and new ideas adopting best practices
23

Senior Claims Specialist Resume Examples & Samples

  • Helps develop and execute the strategies of the practice on creating for larger accounts
  • Support s new business with sales presentations and RFP
  • Regularly meets with office leadership and team leaders to ensure delivery alignment
  • 5+ years claims experience
  • High School diploma required; degree preferred
  • Knowledge of laws, legal codes procedures and processes involving insurance
  • Understand the basic process and value basic data analytics and benchmarking
  • Handle multiple tasks simultaneously and effectively prioritize to meet deadlines
  • Be self-motivated, able to work both independently and within a matrix team structure
24

Life Claims Specialist / Assistant Resume Examples & Samples

  • File and request files during the claim process (this would include ordering files from record retention and from AWD)
  • Registration (computer in-put information regarding the claim)
  • Mail claim forms, checks and correspondence
  • Gather and organize files for internal and state audits
25

Claims Specialist Resume Examples & Samples

  • Strong, relevant legal qualifications (Solicitor or Legal Executive essential)
  • Strong claimant litigation experience; with the ability to draft, issue and progress proceedings to conclusion with minimal guidance
  • Proven experience providing sound commercial advice within a business setting
  • Clear knowledge of CPR and relevant legislation (NRSWA etc)
  • Knowledge of wider law (i.e. tort, land) and experience of self-managing full case load
  • Ability to listen to and understand stakeholder requirements
  • Excellent negotiating skills
26

Claims Specialist Resume Examples & Samples

  • Conduct outbound calls to all policyholders being assigned claims to the team
  • Assist claims supervisor if needed, in training temporary staff during a catastrophe event
  • Answer a high volume of telephone calls and respond to questions by policyholders and other third party stakeholders associated with the claim to provide case management
  • Schedule follow up contact with the policyholder and other third party stakeholders in order to maintain open lines of communication
  • Communicate with adjusting firms to obtain any outstanding documentation in order to process claim
  • Apply National Flood Insurance Program rules and regulations with each claim worked
  • Insure claims are processed within established company and client guidelines through working with other team members and the Claims Supervisor
  • Coordinate and track losses using various in-house and potentially external systems
  • Work with incoming and outgoing communications to ensure timely processing of Claims Department information when received
  • Complete company training program. Program includes inter-departmental training within the Operations department as well as classroom training
  • Ensure all correspondence directed from the Claims Department is professional and complete
  • Work independently as well as within a team environment
  • Maintain an established level of productivity using time management techniques
  • Able to shift between priorities as needed throughout the workday
  • 2+ Years of Office and/or Administrative background
  • 2+ years of insurance claims processing experience preferably in insurance, claims and/or flood insurance
  • The ideal candidate will have experience with phone related customer service and direct customer contact
  • Communication skills including both verbal and written, with specific attention to detail
  • Ability to maintain a high degree of confidentiality and ethical behavior
  • Ability to maintain and display a positive attitude at all times; supporting business needs and changes; supporting continuous improvement; and supporting the National Flood Insurance Program
  • Reliability and dedication to the position is imperative. Position will frequently require overtime hours
  • Proficiency at keying alpha and numeric information with accuracy and speed
  • Knowledge of basic equipment functions, such as how to create and maintain files, printing, copying, faxing, phone messaging and voice mail
  • Ability to work with frequent and multiple policy, procedure, and regulatory changes
  • Ability to manage time through establishment of priorities and proper planning
27

Claims Specialist Resume Examples & Samples

  • Effective communication skills are a must
  • Experience using Microsoft Office applications (i.e. Outlook, Excel, etc.)
  • Must have experience working with data
  • Experience in a medical office setting
  • Medical claims processing experience preferred, but not required
28

Ucs-unemployment Claims Specialist Resume Examples & Samples

  • Respond to a state agency with all pertinent details within the time frame allowed by the state or departmental procedures
  • Initiate timely telephone calls, faxes or emails to customers, completed by co-workers, to obtain, document or pass along needed information
  • Overtime may be required in order to meet state deadlines
  • Previous office experience with an emphasis on organization of work duties and performing job functions independently
  • High ethical standards
  • Ability to handle a high volume of work and work under deadlines
  • Ability to follow policies and procedures; complete administrative tasks correctly and on time
  • High level of professionalism
  • Computer Skills Required
  • Previous experience with Unemployment Insurance and the Unemployment Claims process is helpful
29

Junior Claims Specialist Resume Examples & Samples

  • Determine the amount of benefit payable as a result of the death of a retiree and process payments,
  • Process payments under the fast track payment program,
  • Handles Tier 1 creditor claims,
  • Determine the liability as a result of the Extended Disability Benefit under a PSS Group Contract and sets up the claim
  • Provide guidance to the client (e.g. the group policyholder or beneficiary on requirements needed to settle the claim and disburse the benefit to the legal beneficiary); works with Senior Specialist regarding gaps uncovered
  • Communicate by telephone, correspondence and occasionally in person
  • Serve as a back up to the Support function when needed
  • Handle return of annual tax slips
30

Claims Specialist Resume Examples & Samples

  • Processes claims that pend for various hold reasons to assist in the final determination on claim disposition
  • Processes adjustments related to projects or provider disputes
  • Researches post payment claims issues and takes necessary action for correction
  • Research claims issues and works with other departments to resolve claim issues
  • Preferred 1+ year of experience in Previous claims or health insurance
  • Beginner Ability to multi-task
  • Beginner Ability to work independently
  • Beginner Ability to communicate and make recommendations to upper management
  • Beginner Demonstrated written communication skills
  • Beginner Demonstrated analytical skills
  • Beginner Demonstrated problem solving skills
  • Beginner Demonstrated time management and priority setting skills
  • Beginner Demonstrated organizational skills
  • Beginner Knowledge of healthcare delivery
  • Required Beginner Microsoft Outlook
  • Required Beginner Microsoft Word
  • Required Beginner Microsoft Excel
31

Claims Specialist Resume Examples & Samples

  • Processes adjustments related to projects or provider disputes providing timely follow-up provider call backs
  • Researches complex claims issues and works with all external departments, markets, and providers on claims related content
  • Completes new hire audits
  • Runs and analyzes ad-hoc reports
  • Identify root-cause issues to ensure enterprise solutions and communicate findings as needed
  • Participates in all formal and informal training opportunities
  • Preferred 2+ years of experience in Previous claims or health insurance
  • Required 6 months of experience in Processing of institutional and / or professional claims
  • Intermediate Ability to communicate and make recommendations to upper management
  • Intermediate Ability to work independently
  • Intermediate Demonstrated analytical skills
  • Intermediate Demonstrated written communication skills
  • Required Intermediate Microsoft Word
  • Required Intermediate Microsoft Excel
32

Claims Specialist Resume Examples & Samples

  • Ability to work independently and escalate for assistance as needed
  • Strong communication ability to work with various internal and external parties to resolve member issues
  • Ability to proactively identify payer and provider trends, and to communicate this to management
  • Excellent customers service skills
  • Excellent listening skills and ability to emphasize with members
  • Excellent computer skills and experience in Microsoft Office Suite
33

Claims Specialist Resume Examples & Samples

  • Daily opening and sorting of all claims related correspondence
  • Enters mail received dates into the claims computer system
  • Assists with the scanning process by imaging documents and pertinent information to AS400 IMS/21 system (either individually or by batch mode)
  • Mailing out checks
  • Maintaining a neat and orderly file room
  • Batch processing of claim forms and letters
  • Assisting with special projects and other duties as assigned
  • One year prior office work experience preferred, but will consider recent grads
  • Experience with Microsoft Office suite products
  • Detail oriented and strong time management and communication skills
  • Data entry and scanning experience helpful
34

Claims Specialist Resume Examples & Samples

  • The Claims Specialist sets adequate reserves to ensure proper reporting
  • Compares data on claim form with insurance plan to ascertain completeness and validity of the claim
  • Examines claim form and other records to determine insurance coverage
  • Proactively works to resolve claim as expeditiously as possible
  • Reviews and analyze detailed medical records
  • Calculates reimbursement of benefits according to the schedule of coverage. Runs various claim reports as directed by the account
  • Liaison with Marketing/Customer Service departments
  • Cultivates relationships
  • Incrementally increase productivity without jeopardizing quality
  • Approves claims at the appropriately demonstrated assigned authority level
  • Functions as a resource for examiners and assist with training new examiners and customer service representative
  • Handles difficult phone calls and composes special correspondence
  • 1 – 3 years claims adjudication experience. Will also considerrecent college graduate with a 4 year degree. Majors in Business Admin, English, Finance or Science preferred
  • Ability to multi-task – manages time effectively
35

Claims Specialist Resume Examples & Samples

  • Recognize repetitive problems or issues and escalate as needed
  • Identify exception handling and process per client requirements. When appropriate, assign a script number or NDC number if not provided
  • Input claim requests into adjudication platform maintaining production and accuracy standards. Evaluate system rejections to ensure accuracy and appropriateness
  • Evaluate claim submission, ensure all required information is present and determine what action should be taken. Confirm patient eligibility and verify patient information matches system. Update member’s address to match claim form if necessary
  • Create correspondence to members, internal departments, and external agencies regarding outstanding claims issues. Compose letters to members or pharmacies for those claims with insufficient information or eligibility or benefit issues
  • Handle claims requiring additional research, navigate through appropriate system platforms to perform research and resolve issues. Work with other operational departments to research and resolve claims issues within performance agreement guidelines
  • GED: General Studies (Required) HS: General Studies (Required)
  • Years of Relevant Work Experience 2 - 3 Years
  • Proficient written and oral communication skills; strong customer focus
  • Must be aself-starter and team player
  • Ability to adapt in a dynamic work environment, learn quickly, solve problems and make decisions with minimal supervision
36

Claims Specialist Resume Examples & Samples

  • Relevant professional qualification e.g. (ACII/FCII/CILA)
  • Bachelor’s degree preferred, advanced degree preferred plus 8 years’ experience
  • CPCU, or AIC, or ARM within 3 years of obtaining this position or 20 years or more insurance industry experience exempt
  • Query Management
  • Compliance Management
  • Organization and Prioritizations
  • Market relationship management
  • London Market Negotiation
  • Technical knowledge
37

Senior Claims Specialist Resume Examples & Samples

  • 10+ years claims experience in general liability and construction claims
  • College degree required, law degree a plus
  • Travel required, primarily within California
38

Claims Specialist Resume Examples & Samples

  • Knowledgeable in Excel, Word and PowerPoint
  • Strong Default Mortgage background
  • Accounting and Reconciliation skills
  • Minimum 2 years Investor Claims Experience
  • 5 years Investor Claims Experience
  • 5 years Mortgage Servicing or Default Experience
39

Senior Claims Specialist Resume Examples & Samples

  • Reviews and interprets rebate contract terms and conditions and establishes parameters in the contracting system (CARS) to produce accurate rebate calculations
  • Conducts initial quality check, including formulary compliance, on all claim submissions to ensure rebate eligibility. Resolves issues with account and prepares validation system (ECP) to receive detail claim data
  • Reviews suspect claim records and determines if record should be disputed for payment. Communicates disputed records to account
  • Prepares contracting system to receive validated claim data and calculate rebates. Ensures accurate system results by manually checking calculations
  • Acts as the primary contact point for rebate questions from account, account managers, Contract Administration and Forecast Administration
  • Supports the collection and recording of data critical to contract preformance assessment and rebate forecasting
  • Pharmaceuticals industry
  • Manipulation of large data sets
  • Negotiation/conflict resolution
  • Able to understand and troubleshoot electronic data processing systems
  • Able to construct system workarounds in special circumstances
40

GAT Claims Specialist Resume Examples & Samples

  • English and Japanese (required - for Japanese must be at least able to read, listen and write/type). Proficiency in any of the following languages would be an added advantage - Chinese, Malay, Vietnamese, Thai, Korea
  • Ability to manage time and resources to meet commitments in a dynamic environment and following through on details
  • Strong interpersonal skills and communications skills
  • Able to build professional relationship with business partners internally and externally. Actively responds to business partners' requirement and business priorities
  • Great team player, works well and collaborates with others to achieve quality results
41

Claims Specialist Resume Examples & Samples

  • Acts as Claims Department subject matter expert on departmental and corporate projects. Supports business definition and testing efforts, attends project meetings, maintains project plans and provides internal and external status reports
  • Works with management and associates to document current business and workflow processes and collaborates in identifying, defining and documenting process improvement options and alternatives
  • Researches complex claims issues and works with other departments to resolve. Serves as primary liaison to all external departments, markets, and providers on claims related content
  • Analyzes and trends claims issues, performs true root cause analysis and determines next steps for resolution and process improvement
  • Researches issues, compiles feedback and drafts corresponding business requirements documents and business decision documents as needed
  • Communicates changes in processes, project status and issue resolutions through email, memos, group presentations, and/or individual one-off meetings
  • Performs new hire audits
  • Preferred 3+ years of experience in Previous claims or health insurance
  • Required 2+ years of experience in Claims processing with a solid understanding of internal claims functions, and have performed at least 5 of the duties found in the Claims II role (found in job description)
  • Advanced Ability to communicate and make recommendations to upper management
  • Advanced Ability to effectively present information and respond to questions from peers and management
  • Advanced Ability to multi-task
  • Advanced Ability to work in a fast paced environment with changing priorities
  • Advanced Ability to work independently
  • Advanced Demonstrated analytical skills
  • Advanced Demonstrated ability to deal with confidential information
  • Advanced Demonstrated customer service skills
  • Advanced Demonstrated interpersonal/verbal communication skills
  • Advanced Demonstrated organizational skills
  • Advanced Demonstrated problem solving skills
  • Advanced Demonstrated time management and priority setting skills
  • Advanced Demonstrated written communication skills
  • Advanced Knowledge of healthcare delivery
42

Senior Claims Specialist Resume Examples & Samples

  • Communicate with store personnel and injured customers
  • Proactive communication in resolution of in-house customer claims
  • Act as an internal resource for General Liability questions
  • Provide reports via excel as required
43

Claims Specialist Resume Examples & Samples

  • Researches, analyze and resolves customer deductions
  • Establish relationships with the appropriate business unit and corporate personnel
  • Advise the business of deduction problems and to the supervisor
  • Other duties as assigned by the FSCM Supervisor
  • 1 to 3 years experience in a business related field
  • Previous experience desired in deduction management
44

Claims Specialist Resume Examples & Samples

  • Proficient in Microsoft Word, Excel, Access, PowerPoint, and Outlook
  • Committed to superior customer service with a quality focus
  • Listens well and communicates effectively both verbally and written
  • Excellent self-management skills & ability to work independently
  • Understand multiple client programs, follow process guidelines
  • Demonstrate strong ability to identify, analyze and solve problem for customer resolution
  • Claims adjudication experience or relevant experience
45

Senior Claims Specialist Resume Examples & Samples

  • Bachelor’s degree preferred, advanced degree preferred plus 10 years’ experience managing Financial & Executive Lines claims (D&O, E&O (including Cyber), EPLI, Fiduciary Liability, Fidelity/Crime)
  • Knowledge of claims handling, processes and best practices procedures
  • Ability to conduct claim best practice audits, including outlining findings and recommendations with goal of improving claim program
  • Strong communication skills both verbal and written with senior management, clients, and vendors
  • Proven success for working with different personalities
  • Ability to work effectively in team environment
  • Must be able to handle multiple tasks simultaneously and manage deadlines
  • Ability to analyze and report financial data
  • Obtains relevant technical information to support decision making
  • Strong presentation skills to be effective in sales meetings with prospects
  • Proven ability to work independently
  • Understands company products, services, global network, and industry practices
  • Data analysis and benchmarking skills including ability to analyze claim data and develop solutions to potential adverse trends
46

Claims Specialist, Complex Casualty Ontario Resume Examples & Samples

  • Strategy Execution
  • Resolve complex claims adhering to established claims settlement policies and processes
  • Execute policies and procedures governing the establishment and management of 3rdParty Liability, Bodily Injury case reserves
  • Ensure consistency in behaviour and actions in line with company core values and exercise sound judgment in non-routine and complex situations
  • Support the development of analysts through empowerment and coaching
  • Organizational Effectiveness
  • Apply established decision criteria triggering the management and resolution of complex claims
  • Execute authority to fairly settle complex claims up to authority limit
  • Accountable for adequacy of Bodily Injury case reserves on their files
47

Workers Comp Claims Specialist Resume Examples & Samples

  • Evaluate claims to determine potential exposure; make recommendations concerning the value of the claim; oversee litigation and assist in the negotiation of settlements
  • Proactively oversee the Worker’s Compensation claims management activities in assigned territories with a special focus on cost containment strategies
  • Manage and target aggressive resolution of case inventory, and resolve problems of varying scope and complexity in accordance with state statutes
  • Evaluate claims for settlement and appropriateness of established reserves
  • Attend claim reviews; complete follow up action to ensure expedited resolution
  • Provide daily support / guidance to teammates, claims adjusters, insurers, and defense counsel by answering claims-related questions or concerns in the administration and management of claims, return-to-work issues, and other claim matters
  • Analyze claims data to identify needed loss control interventions and assist with the development of appropriate loss prevention programs as requested
  • Provide training and education to facilities on claim processes and procedures
  • Coordinate handling of claim subpoenas in an expeditious manner
  • Generate reporting and analysis on assigned case inventory
  • Escalate exceptions, outliers, or circumstances that are out-of-norm, as they occur, and seek guidance in case resolution
  • Participate in meetings, presentations, and special projects, as necessary
  • Commitment to Company’s values of Service Excellence, Integrity, Team, Continuous Improvement, Accountability, Fulfillment and Fun with ability to demonstrate those positively and proactively to patients, teammates, management, physicians, and/or vendors in every day performance and interactions
  • Demonstrated sound judgment and initiative in working within departmental and corporate guidelines, including the ability to maintain confidentiality of information
  • Strong written, verbal, and interpersonal communications skills including ability to listen attentively and to communicate information clearly and effectively throughout all levels of the organization with audiences of varying degrees of familiarity with material
48

Complaints / Claims Specialist Resume Examples & Samples

  • Providing expertise or general support in reviewing, researching, investigating, negotiating and resolving all types of claims and complaints / grievances
  • Coordinating efforts with other areas as necessary
  • Communicating issues, implications and decisions with appropriate parties
  • Analyzing and identifying trends for complaints / grievances
  • Ensuring optimal performance re: timely, accurate, effective and complete responses
  • Verifying that all documentation, letters and attachments meet customer, regulatory and internal requirements
  • Preparing for and participating in audits
  • Organizing, checking, pulling, reviewing and saving files
  • Maintaining positive working relationships with internal and external customers including regulators
  • Word & Excel proficiency
  • Must be proficient in developing accurate, easy to understand and thorough correspondence
  • Previous Behavioral Health experience
  • Must live within a commutable distance of San Francisco, CA
  • Previous Appeals and/or Complaints/Grievances experience
  • Previous Claims experience
  • Bachelor's Degree in Healthcare, Behavioral Health, Business, Psychology or English
49

Claims Specialist Resume Examples & Samples

  • Communicate and go on-site as necessary to locations to assist with all internal claims management activities
  • Maintain an internal active diary system of claims that are being managed
  • Coordinate for team internal claims update to Risk Management as requested / required, such as an internal claims review
  • Monitor claims reporting to third party administrator and report claims as required
  • Work with stores safety to help identify and reduce claim trends
  • Monitors and reports the effectiveness of third party claims administrators with regard to this position’s assigned case load
  • Responsible for legally mandated mailings
50

Junior Warranty Claims Specialist With English & German Resume Examples & Samples

  • Communicative English and German (mainly written and reading skills on level B2, communication can be passive)
  • Data processing accuracy, detail oriented and ability to evaluate/research a warranty claim
  • Experience in Warranty is preferred but not required
51

Claims Specialist, Senior Resume Examples & Samples

  • Processes all types of medical claims and adjusts medical disputed claims (Professional and Facility) according to department, contract, and regulatory requirements
  • Performs prepayment audit on all types of medical claims (Professional and Facility) according to department, contract, and regulatory requirements
  • Updates authorization information based on information obtained from provider
  • Troubleshoots problem claims to resolve provider issues or systematic issues
  • Verifies and interprets information in all vendor contracts to resolve issues
  • Trains analysts and monitors general office support functions as needed
  • Analyzes work processes, identifies areas needing improvements and initiates necessary steps to make changes
  • Participates in the continuous quality improvement of IMCS core business system
  • Computer literate
  • Individual must be reliable, dependable, and punctual
  • Ability to make decisions regarding escalation of referrals to Care Management
  • Knowledge of all types of professional claims
  • Knowledge of compliance related to the processing of claims
  • Knowledge of different sources of authorization documentation
  • Ability to update authorization information based on information obtained from facilities
  • Ability to read and interpret all vendor contracts
  • Knowledge of DRG pricing
52

Claims Specialist Resume Examples & Samples

  • Processes all types of professional claims and adjusts professional disputed claims according to department, contract, and regulatory requirements
  • Performs prepayment audit on all types of professional claims according to department, contract, and regulatory requirements
  • Processes simple facility claims as needed according to department, contract, and regulatory requirements
  • Answers telephone inquiries through the “Automated Call Distributor (ACD) Telephone System” as needed
  • Identifies individual provider needs and take appropriate steps to satisfy those needs
  • Updates authorization information based on information obtained from facilities
  • Analyzes work processes and identifies areas needing improvements
  • Follows unit procedures for performing call processing, claim adjustments and denials and references Policies and Procedures, job aides, provider contracts, and other reference materials to assure complete and accurate decisions
  • Excellent customer service and telephone skills
  • Ability to work in an environment with fluctuating workloads
  • Ability to solve problems systematically, using sound business judgment
  • Ability to make decisions with every call and handle escalated issues
  • Familiarity with ICD-9 and CPT codes
  • Ability to research and verify claims payment issues
  • Knowledge of medical terminology and pricing options
53

Claims Specialist Senior Resume Examples & Samples

  • Handles the most complex/challenging claims issues
  • Ensures the accuracy and completeness of claims forms
  • Investigates coverage questions and problems
  • Works closely with clients, producers, client service staff, insurance carriers
  • Identifies and resolves complex problems in a timely fashion following established guidelines
  • May provide guidance and coaching to lower level staff
  • Operates independently and can service the largest clients and/or resolve the most complex problems
  • Has a solid understanding of claims processing and the insurance brokerage business
  • Works with Director of Claims in support of quality claims control
  • Travel as needed. (Minimal)
  • Ability and willingness to take initiative
  • Bachelor’s degree or equivalent combination of education and experience required
  • Experience in claims management processes and system requirements preferred
  • 5 or more years related professional experience
  • Good understanding of claims processing and the insurance brokerage business
  • Licensing required
54

General Liability Claims Specialist Resume Examples & Samples

  • Juris Doctor and 1 or more years of experience in the Claims Handling or Insurance area
  • 3 or more years of commercial general liability claims handling experience
  • AIC, SCLA and/or CPCU designation
55

Wc-claims Specialist Resume Examples & Samples

  • Federal
  • USL& H
  • Jones Act; DBA (Defense Based Act)
  • 7 or more years of claims handling experience with 2 or more years in USL& H ; Jones Act; DBA (Defense Based Act)
56

Claims Specialist Resume Examples & Samples

  • Bachelors Degree and 2 or more years of claims handling experience
  • At least 1 year in the Claims Foundational Training Program
  • 2 or more years of Auto Liability claims handling
  • Strong communications, analytical, negotiation and customer service skills
  • Advanced data gathering and problem solving skills
57

Professional Liability Claims Specialist Resume Examples & Samples

  • 7 or more years of claims handling experience with 2 or more years in professional liability, EPLI and/or general liability claims
  • Ability to obtain and maintain required adjuster license
  • AIC, SCLA and/or CPCU
58

General Liability Claims Specialist Resume Examples & Samples

  • At least 2 years of Commercial Liability Claims handling experience
  • Associate or Bachelors Degree
  • Experience handling Commercial General Liability Claims
  • Willingness to embrace the Zurich Basics of Integrity, Sustainability, Customer centricity, excellence and Teamwork
59

Claims Specialist, General Liability Resume Examples & Samples

  • Bachelor’s Degree and 3 or more years of directly related experience managing a claims caseload for a P&C line of business
  • Experience that includes adjudication of GL claims
  • Strong communication, analytical, negotiation and customer service skills
60

Claims Specialist Resume Examples & Samples

  • Bachelors Degree and/or related Claims or Veterinary industries experience. Related experience may include previous experience in an office environment that required computer work, organization, strong communications, customer service and negotiation
  • Experience gathering data, designing and testing solutions to problems, and formulating plans as well as managing multiple projects simultaneously in a fast paced environment
  • 3 or more years of related Claims or Veterinary industries with Bachelors Degree OR
  • 4 or more years of related Claims or Veterinary industries without Bachelors Degree OR
  • 2 or more years of related litigation experience with a Juris Doctorate
  • Fundamental knowledge of the Claims or Veterinary industries industry, claims and the insurance legal and regulatory environment
  • A functional and developing knowledge of the legal statutes and procedures
  • A thorough functional knowledge and skill of claims handling
  • Negotiation Experience
  • Travel required (0-25%)
  • 3 or more years of claims handling experience or veterinary industry experience
  • Experience in a work environment that required collaboration across work groups
  • Ability to effectively present information to LOB manager, claimants and customers
61

Claims Specialist Resume Examples & Samples

  • Bachelors Degree and/or related industry experience. Related experience may include previous experience in an office environment that required computer work, organization, strong communications, customer service and negotiation
  • 3 or more years of related experience with Bachelors Degree OR
  • 4 or more years of related experience without Bachelors Degree OR
  • Fundamental knowledge of the insurance industry, claims and the
  • Insurance legal and regulatory environment
  • Travel required (0-5%)
  • 3 or more years of claims handling experience in line of business
62

Liability Claims Specialist Resume Examples & Samples

  • NY Labor Law claims experience
  • Strong Organization and time management skills
  • AIC, SCLA and/or CPCU designations
63

Claims Specialist Resume Examples & Samples

  • 6 Or More Years Of Related Auto Liability Experience
  • Bachelors Degree Or Equivalent
  • Experience in line of business
  • Willingness to embrace the Zurich Basics of integrity,
  • Sustainability, customer-centricity, excellence and teamwork
  • Bachelors Degree and/or related industry experience. Related experience may include previous experience in an office environment that required computer work, organization skills, strong communications, customer service and negotiation skills, experience gathering data, designing and testing solutions to problems, and formulating plans as well as experience managing multiple projects simultaneously in a fast paced environment
  • 6 or more years of related experience with Bachelors Degree OR
  • 7 or more years of related experience without Bachelor’s Degree
  • 2 or more years of demonstrated management experience including
  • Coaching and mentoring
  • 4 or more years of claims, insurance or litigation experience
  • Must have experience collaborating across work groups
  • A functional knowledge of legal statutes and procedures
  • Thorough knowledge of the insurance industry, claims and the
  • Travel required 0-20%
64

Subrogation Claims Specialist Resume Examples & Samples

  • Assess liability and analyze exposure on assigned matters
  • Hire appropriate and effective counsel and expert resources
  • Analyze financial dynamics and directly handle negotiations
  • Responsible for achievement of individual subrogation goal established annually, typically $7-$9M, while possessing $1,000,000 in indemnity settlement authority and $300,000 in expense authority on each matter
  • Achieve optimum subrogation results on assigned matters through direct handling, as well as effective management and direction to Property Large Loss adjusters, cause and origin investigators, and subrogation counsel on the investigation, evaluation and strategic planning related to these cases
  • Mitigate all subrogation expenses in order to contribute to corporate recovery objectives
  • Attend mediations, settlement conferences and trials as required
  • Effective and timely reporting on subrogation matters, sharing any trends or legal decisions that affect subrogation recovery with business leaders
  • Provide oversight, direction and training of internal partners in the Central Recovery Office, as well as the Property Large Loss and Field Operations
  • Participate as a subject matter expert in ancillary projects that impact subrogation
  • Embrace enterprise values of customer focus, diversity and inclusion, financial discipline, integrity, team work and a winning spirit by meeting the leadership imperatives of delivering results, inspiring excellence, being a team player, forward thinking, championing talent and becoming a trusted decision-maker
  • Juris Doctorate strongly preferred with 4+ years of legal experience; alternatively, 8-10 plus years of carrier subrogation experience in first party property matters
  • Strong knowledge of theories of liability, and understanding of legal procedures and strategies
  • Excellent analytical, critical thinking and problem solving skills
  • Strong negotiation and communication skills, both written and verbal
  • Ability to work independently and embrace positive accountability
  • Inquisitive, ambitious, and a bias for improvement
  • Working knowledge of property coverage and the insurance industry
65

Claims Specialist Resume Examples & Samples

  • Manages moderate to high complexity commercial subrogation/recovery claim investigation involving the property line of business. Determines if a claim should be negotiated, arbitrated or litigated through conclusion based on a thorough investigation and resolution strategy. Effectively manages loss costs and recovery claim expenses
  • Manages all types of investigative activity or litigation on claims, including the posting of appropriate reserves in a timely manner. Coordinates discovery and litigation strategy with staff counsel or panel attorneys
  • Negotiates moderate to high complexity settlement packages within scope of authority, settling recovery claims in the most cost effective manner
  • Makes recommendations on subrogation/recovery claims processes and resolution strategies to management
  • Analyzes recovery claims activities; prepares and presents reports to management and other internal business partners and clients
  • Works with attorneys, account representatives, agents and insureds regarding the handling and/or disposition of moderate to high complexity subrogation/recovery claims
  • Keeps current on state/territory regulations and issues, industry activity and trends. May participate in industry trade groups
  • Provides guidance and assistance to less experienced claims staff and other functional areas where appropriate
  • Responsible for input of data that accurately reflects claim circumstances and other information important to our business outcomes
  • Advanced technical and product specific expertise, subrogation/recovery claims resolution skill and knowledge of insurance and underlying claim principles, practices and procedures
  • Strong communication, negotiation and presentation skills. Ability to effectively interact with all levels of CNA's internal and external business partners
  • Creativity in resolving unique and challenging business problems
  • Knowledge of Microsoft Office Suite and other business-related software
  • Ability to manage and prioritize multiple projects
  • Ability to evaluate claims based on a cost benefit analysis
  • Ability to fully comprehend moderate to complex claim facts and issues; and to further articulate analyses of claims in presentations to business partners and management as well as in internal reports
  • Ability to implement strategies with a proactive long-term view of business goals and objectives
  • Bachelor's degree or equivalent experience. Professional designation preferred
  • Typically a minimum three to five years commercial property subrogation/underlying property claims experience
66

Claims Specialist Resume Examples & Samples

  • Manages moderate to high complexity commercial recovery claim investigation involving ocean marine subrogation/recovery claims. Determines if a major claim should be negotiated, arbitrated or litigated through conclusion based on a thorough investigation and resolution strategy. Effectively manages loss costs and recovery claim expenses
  • Manages all types of investigative activity or litigation on major ocean marine claims, including the posting of appropriate reserves in a timely manner. Coordinates discovery and litigation strategy with staff counsel or panel attorneys
  • Makes recommendations on recovery claims processes and resolution strategies to management
  • Works with attorneys, account representatives, agents and insureds regarding the handling and/or disposition of moderate to high complexity recovery claims
  • Keeps current on state/territory regulations and issues, industry activity and trends related to ocean marine. May participate in industry trade groups. Understands and can apply admiralty law/statutes including, but not limited to COGSA, Montreal Convention and Hague Convention, as part of strategy to maximize recovery
  • Provides guidance and assistance to less experienced claims staff and other functional areas when/where appropriate
  • Effectively manages vendor relationships to include the expansion contraction vendor model with key vendor partners
  • Solid knowledge of claims and insurance theory and practices
  • Demonstrated technical expertise, product specific knowledge, and negotiation skills
  • Strong interpersonal and communication skills. Ability to effectively interact with all levels of CNA’s internal and external business partners
  • The ability to exercise independent judgment and make critical business decisions effectively
  • Typically a minimum three to five years ocean marine and/or property claims experience
67

Claims Specialist Resume Examples & Samples

  • Interprets more complex or unusual policy coverages and determines if coverages apply to claims submitted, escalating issues as needed
  • Prepares timely and thorough coverage analysis and may occasionally assign counsel on an insured’s behalf
  • Recommends appropriate reserves and attempts to effectively settle claims in most cost effective manner and ensuring timely issuance of disbursements
  • Coordinates and performs investigations and evaluates claims and exposure through contact with insureds, brokers, other insurance carriers and defense counsel
  • Utilizes negotiation skills to develop complex settlement packages or suggest resolution strategies
  • Works with defense counsel, underwriters, brokers, and insureds regarding the handling and/or disposition of complex claims
  • Analyzes claims activities and prepares reports for management. May be responsible for special projects and presentations
  • Solid knowledge of claims and insurance industry theory and practices
  • Demonstrated technical expertise and product specific knowledge
  • Strong interpersonal, communication and negotiation skills. Must have the ability to effectively interact with all levels of CNA's internal and external business partners
  • Ability to exercise independent judgment and make critical business decisions effectively
  • Solid knowledge of Microsoft Office Suite as well as other business-related software
  • Juris Doctorate strongly preferred. Professional designations preferred
  • Typically a minimum two to five years claims experience in professional liability or 2 plus years in a law firm handling professional liability claims. D&O experience preferred
68

Claims Specialist Resume Examples & Samples

  • Demonstrated claims management experience in workers comp, auto and general liability issues
  • Strong analytical, critical thinking, problem solving, judgment, negotiating, influencing, and decision making skills. Ability to maintain confidentiality, tact, and diplomacy
  • Working knowledge of federal and state disability laws; specifically FMLA, CFRA, ADA, HIPAA, etc
  • Familiarity with job restrictions, accommodations and functional capacity exams
  • Strong working knowledge of workers' compensation claims and process
  • Strong organizational skills: comfortable managing many multiple and varied complex individual situations
  • Experience counseling and working with employees regarding disability benefits, vendor claims personnel, internal and external legal departments
  • Excellent facilitation and oral and written communication skills; ability to prepare clear and concise reports and deliver formal presentations or training to senior management and other audiences
  • Demonstrated proficiency with business applications, such as Microsoft Office suite and human resource information systems
  • Proficient in managing multiple sources of data and integrity; ability to identify trends, design reports, conduct audit and analysis of data
  • Clear thinker who understands the development of and has ability to correctly interpret policy
  • Flexibility and adaptability in dealing with rapidly changing priorities and demands necessary
  • Ability to make sound judgments requiring confidentiality, tact, and diplomacy in dealing with a variety of personalities and situations
  • Bachelor's degree (preferred) and five – seven years of relevant experience, or combination of education and relevant experience
  • California State disability expertise required
69

Subrogation Claims Specialist Resume Examples & Samples

  • Investigate, negotiate, subrogate and settle first and third party losses
  • Maintain recovery targets set forth each month
  • Ensure cases are called as scheduled and aging is maintained
  • Demonstrate professionalism when dealing with contacts
  • Maximize Collection efforts and customer satisfaction
  • Practice collection and research techniques to ensure timely resolution
  • Maintain accurate and complete documentation of all activity
  • Submit claims for referral and write-off
  • Develop a systematic approach for case reviews and calls
  • Include Customer Relations when addressing sensitive case issues
  • Include Hertz Sales when addressing sensitive case issues
  • Respond to inquiries within 24 hours to maintain customer service
  • Other duties as assigned by supervisor/manager
  • One year Insurance Claims experience and/or collections experience
  • Basic working knowledge with Microsoft Word and Excel (pre – employment assessment required)
  • Excellent customer service and telephone skills/experience
  • Excellent organizational skills and ability to handle multiple tasks
  • Must be able to work well with others
  • Must be attentive to detail
  • Must be an independent worker and able to work with minimal supervision
  • Criminal background check due to access to Personal identifiable Data (PID)
70

Senior Claims Specialist Resume Examples & Samples

  • Good interpersonal and customer services skills
  • Good data management and analytical skills
  • Attentive to details and patient
  • PC literate in Word, Excel and Chinese word processing
  • Good command of spoken and written English and Chinese
  • Candidates with less experience will be considered as Claims Analyst or Claims Assistant
71

Consumer Claims Specialist Resume Examples & Samples

  • Responsible for receiving, organizing, reviewing, and resolving product complaints related to product safety and quality for Philips North America products
  • Requests complaint failure investigations; and, ensures returned products associated with product complaints are forwarded to the appropriate facility for investigation
  • Prepare and distribute written correspondence to the consumer regarding product complaint that resolve the consumer’s issue
  • Responsible for one time consumer resolution for all products
  • Responsible for check requests to settle consumer claims along with “closure”/disclaimer letter
  • Applies acquired job skills, company policies, and procedures to complete assigned tasks but recognizes the need for deviation occasionally
  • Requires 1-2 years of minimum experience to manage consumer relationship
  • Minimum 1-2 years of experience using Microsoft Office
  • Can coordinate multiple tasks simultaneously
  • Knowledge of working with Consumer Relationship Management (CRM) system like Salesforce
  • Knowledge of complaint handling
72

Senior Claims Specialist Resume Examples & Samples

  • Utilize 3rd party software to price claims for various markets
  • Monitor and release of all claims in the adjudication queue folder
  • Quality check claim batches adhering to weekly claim run deadline
  • Responsible for handling emails including but not limited to reprocessing requests and inquiries from internal and external sources
  • Attend internal and external operational and/or provider related meetings as assigned
73

Excellent Recent Grad Claims Specialist Position Resume Examples & Samples

  • Desire to learn
  • Desire to grow within a company
  • Manage claims through the life cycle
  • Information gathering and research
  • Issue resolution with clients and carriers
  • Status reporting
  • Ad hoc reporting
  • Strong MS Excel skills including functions and pivot tables
  • Ability to work in a team and support the team
74

Claims Specialist Resume Examples & Samples

  • Processing member claims
  • Making outbound phone calls to members or providers to get required information for processing
  • Investigating claims for required processing information
  • Knowledge in Medical Terminology, CPT-4 , ICD-9, ICD-10 and revenue code
  • Team player, ability to work with tight schedules, overtime and multiple priorities
  • Able to meet deadlines and work under pressure
  • Excellent communication skills, both oral and written, English and Spanish
  • Experience as Claims Specialist (2 years minimum)
75

Leave of Absence Claims Specialist Resume Examples & Samples

  • Communicates decisions and on-going expectations with Employees, Manager and Human Resources. Communicate as necessary with employees, supervisors, and departments to keep employees informed and up to date through FMLA leave application process, period of FMLA leave, and return to work
  • Counsel employees and supervisors about FMLA rights and responsibilities while maintaining appropriate confidentiality of employee medical information
  • Interface with Worker's Compensation to ensure that Worker's Compensation claimants are apprised of FMLA and ADA rights and obligations per law and company policy
  • Performs complex research using PeopleSoft, knowledge base, event management system, Total Benefits Administrator Pension System, Kronos Automated Time Collection system, Authoria, and Microsoft based PC application (Excel, Access, Works) to perform job functions. Create and utilize queries in both PeopleSoft and vendor maintained applications. Communicates outcome in a timely fashion. Responds to inquiries from disability carriers regarding any information needed for claim processing
  • Review and assess current FMLA/STD leave practices and propose revisions to improve overall accuracy, consistency, efficiency, and communication
76

Senior Claims Specialist Resume Examples & Samples

  • Maintain control of outside vendors/attorney and their expenses by directing assignments to them, and limiting the scope of assignments so as to maximize cost efficiency while minimizing delays in claim handling. Such vendors/attorneys must not be used unless pre-approved by the manager. Adhere to provisions of Litigation Management Program and cost containment principles
  • Maintain compliance with Fair Claim Practices Act or rules and internal instructions
  • Knowledge of Auto and General Liability policy coverage
  • Knowledge of tort law, motor vehicle law, basic reinsurance, property damage, bodily injury knowledge required and coding related to claims technical matters
77

Senior Claims Specialist Resume Examples & Samples

  • Establish proper loss reserve and negotiate loss settlements
  • Maintain control of outside vendors/attorneys and their expenses by directing assignments to them and limiting their scope to maximize cost effectiveness while minimizing delays in claims handling. Such vendors/attorneys must not be used unless pre-approved by the department manager
  • Maintain compliance with Workers' Compensation procedure and requirements established by regulatory authorities
  • Pursue Workers' Compensation liens and subrogation when appropriate
  • Maintain compliance with claims practice rules and internal instructions
  • Keep supervisor advised of significant developments in claims
  • Answer correspondence and inquiries promptly from brokers/agents, insureds, claimants, doctors, attorneys, outside vendors, TMM employees, etc
  • Minimum five (5) years of experience investigating and handling lost time Workers' Compensation
  • Experience in handling claims and detailed knowledge of applicable state jurisdictional Workers' Compensation rules and regulations for GA, TN, MS, AL – required; additional states – FL, NC, SC
  • Knowledge and understanding of medical and legal terminology which may come within the purview of Workers' Compensation claims
  • Computer literate (MS Windows preferred)
  • Valid Georgia Insurance Adjuster License or CWCP
78

Home Claims Specialist Resume Examples & Samples

  • Previous experience in a customer-facing role, including demonstrable evidence of providing high standards of customer care are essential
  • Numeracy and literacy (equivalent to GCSE level Maths and English - Grade C and above)
  • Problem Solver
  • Proactive and pragmatic approach
79

IDI Claims Specialist Resume Examples & Samples

  • Manages assigned caseload with limited supervision
  • Provides timely, balanced and accurate claims reviews, documentation and recommended decisions in a time sensitive and fast-paced environment
  • Compiles file documentation and correspondence requiring extensive policy and factual detail. Identifies information and resources needed to adjudicate claim
  • Conducts lengthy detailed information-gathering phone calls that obtain medical condition details, financial details, occupational details and other information
  • Proficiently calculates benefits due after elimination period, COLA, Social Security Offsets, and residual and non-routine payments
  • Drafts responses to Department of Insurance and Presidential complaints
  • Identifies and refers appropriate matters to legal counsel
  • Represents MetLife at depositions and trials
  • High School Diploma or Equivalency required; Bachelor’s Degree strongly preferred
  • 1+ year related business experience
  • In order to post for this position, you need the proper work authorization to work in the country where the position is located and not require relocation assistance
80

LTD Claims Specialist Trainee Resume Examples & Samples

  • Provide timely and accurate communication, information gathering, and rendering decisions on Long-term Disability (LTD) claims according to provisions of LTD certificates
  • Communicate with a variety of constituents (claimants, doctors, nurses, employers, and attorneys) to gather information relevant to rendering decisions based on the provisions of the policy
  • Learn to use appropriate systems, tools and resources to research and document claims
  • Learn to develop an action plan and identify the Likely Claim Progression including identifying the return to work potential
  • Complete regular updates on financial offsets such as SSDI
81

STD / Fmla Claims Specialist Resume Examples & Samples

  • 2-4 years Customer Service background
  • High School Diploma/ GED
  • Bachelor’s Degree Preferred and 2-4 years’ customer service experience
82

A&H Claims Specialist Resume Examples & Samples

  • Compiles file documentation and correspondence requiring extensive policy and factual detail
  • Communicates decisions to policyholders in verbal and written form
  • Refers to external and internal resources, such as physicians, attorneys and CPAs to gather data such as medical/occupational information in order to ensure well-reasoned decisions
  • Clarifies and reconciles inconsistencies
  • 3+ years of experience in insurance claims
83

Meditech Claims Specialist Resume Examples & Samples

  • MEDITECH 6.1 Billing/Accounts Receivable building required
  • Testing and training of claims forms to include all facets of electronic and paper based claims including 5010, 835 and 837s required
  • Identify improvement opportunities or best practices and make recommendations for optimizing workflow
  • Provide consulting services in all areas of healthcare revenue cycle including: Patient Access, Registration/Admission, Patient Financial Services, and Decision Support/Analytics
  • Maintain regular communication with client, vendor, team members and team leaders regarding project issues, risks, and needs
  • On occasion, may be required to lift and/or carry up to 25 lbs
  • Required to use computer for long periods of time
  • Candidates may live anywhere in the contiguous US and travel 75-100%, as needed by project
  • Maintains at least 85% billable utilization rate
84

Subrogation Claims Specialist Resume Examples & Samples

  • 1+ years of experience in insurance, claims or collection and recovery fields is a plus
  • Prior knowledge of insurance claims or debt recovery is preferred
  • Adjusters license preferred, but not required
85

Claims Specialist Resume Examples & Samples

  • Provider billing files: Statewide responsibility for processing service provider claims for Title XIX members
  • Monitoring approved and denied claim files in accordance with Division and AHCCCS regulations to ensure proper adjudication and audit compliance
  • Reporting member insurance benefits not identified at time of claim submission to AHCCCS, with high volume of customer interaction
  • ReversalNoided claims: Statewide responsibility for research of service provider payments. Processes provider initiated and management approved claim line Reversals and claim line Voids
  • Researching and providing technical assistance to contracted service providers, Division staff and other external entities relating to claims processing
  • Assists with special projects and perform other related work as required
  • Knowledge of principles and practices of accounting
  • Knowledge of AHCCCS rules and regulations as applied to processing medical claims, diagnostic and procedural coding used on medical claims
  • Excellent Customer Services skills a must
  • Comprehensive oral and written communication skills
  • Problem solving, analytical, and research skills
  • Ability to analyze billing problems and recommend usable solutions, the ability to diffuse and resolve complicated issues while maintaining professional relationships, provide training to mixed groups of diverse backgrounds
  • Ability to cross-train to other duties within the unit
  • The ideal/preferred candidate will be familiar with medical claims processing, third party liability and/or Coordination of Benefits
86

LTD Claims Specialist Resume Examples & Samples

  • Independently assess, analyze and render appropriate claim decisions pursuant to certificates
  • Adhere to federal and state law to maintain appropriate and timely claim outcomes
  • Articulate and document their rationale for claim direction, possess the autonomy to take steps outside of CMG guidelines to the extent supported by documented rationale and the facts of the claim file
  • Utilize tools independently and accurately to identify work to be completed across the entire claim block, prioritize work, determine if/when to involve specialty resources such as clinical staff to obtain additional information on a claim
  • 3-5 years’ long term disability claims experience
  • Strong communication skills, both written and oral
  • Comfortable working with multiple priorities in a changing environment
87

Claims Specialist Resume Examples & Samples

  • Researching and identifying suspicious activity through comparative analysis
  • Handling escalated calls and complaints
  • Assisting in the development of more junior level Claims Specialists
  • Preparing case documents for security and law enforcement agencies
88

Senior Claims Specialist Resume Examples & Samples

  • Analyzes, investigates, and evaluates the loss to determine coverage and claim disposition. Utilizes CMS to document claims and to diary future events or follow-up
  • Within prescribed settlement authority for the line of business, establishes appropriate reserves for both indemnity and expense and reviews on a regular basis to ensure adequacy. Makes recommendations to set reserves at appropriate level for claims outside of authority level
  • Monitors the case resolution process. Actively participates in mediations and arbitrations, within limit of settlement authority
  • Participates in Claims audit process
  • May provide claims marketing services by participating in meetings with brokers, risk managers and reinsurers
  • As required, maintains insurance adjuster licenses
  • Bachelors' and/or advanced degree required. J.D. preferred
  • 5+ years claims/legal experience, with Management Liability experience preferred
  • Functional knowledge of claims handling concepts, practices and techniques, to include, but not limited to coverage issues and product line knowledge
  • Functional knowledge of law and insurance regulations in various jurisdictions
  • Demonstrated strong negotiation skills
89

Unemployment Claims Specialist Resume Examples & Samples

  • Receive and prioritize claims, questionnaires and other unemployment related data
  • Analyze individual case information by reviewing data accessed through the PC, from documented telephone calls or document images, to determine if the facts warrant a response
  • Using the details regarding an employee’s separation provided by the client, interpret and apply state laws and regulations in response to unemployment documents
  • Works as a team with our Unemployment Insurance Consultants to ensure accurate and necessary information retrieved from customers is documented clearly and thoroughly into our database
  • Ensures that work is accurate and complete, processed in a timely manner with proper spelling and grammar
  • Investigates and resolves state agency concerns with supervisor, other departments and/or State Relationship Managers in a timely manner
  • Associate’s degree (A.A.) or equivalent from two-year college or technical school; or two years customer service related experience and/or training; or equivalent combination of education and experience
  • 2-3 weeks of immediate, mandatory and uninterrupted training are required upon hire
  • Ability to work well within a team
  • Excellent interpersonal, oral and written communication skills
  • Self-motivated with high level of initiative
90

Claims Specialist Resume Examples & Samples

  • Worker characteristics are normally acquired through completion of an undergraduate 4-year degreed program, completion of an in-house casualty training program, and at least 6 months related experience; or equivalent combination of education and experience
  • Requires knowledge of established Company policies and procedures, with emphasis in claims operations
  • Written and verbal communication skill to effectively and professionally negotiate with claimants, insureds, attorneys, etc
  • Work is of a technical nature and requires the analytical ability necessary to analyze, interpret and evaluate relevant information essential in resolving low to moderate value, liability and bodily injury claims
  • Requires critical attention to detail and good organizational skills to manage a high volume of claims
91

PIP Claims Specialist Resume Examples & Samples

  • Worker characteristics are normally acquired through completion of an undergraduate 4-year degree program, completion of an in-house training program, and at least 6 months of related experience; or equivalent combination of education and experience
  • Requires ability to acquire basic knowledge of established Company policies and procedures, with emphasis on claims operations
  • Professional written and verbal communication skills, including presentation skills, to effectively and professionally communicate with claimants, insureds, attorneys, medical professionals, etc
  • Requires team building and customer relationship skills
  • Work is of a technical nature and requires the analytical ability to analyze, interpret, and evaluate relevant information essential in identifying an appropriate treatment plan and resolving payment for such a plan and/or for lost wages
  • Requires some exercise of independent judgment which may have significant impact on the Company in areas such as costs, consumer loyalty, and legal complications
  • Requires critical attention to detail, ability to prioritize, and good organizational skills to manage a high volume of claims
  • Requires basic skills in MS Word and Excel
  • Experience in a medical bill processing environment, including use of related software is preferred, but not required
  • General knowledge of Workers' Compensation claims is preferred, but not required
92

Complex Claims Specialist Resume Examples & Samples

  • Effectively evaluate and resolve coverage issues for all lines of business and all liability claim types
  • Investigate the claims through telephone, written correspondence, and/or personal contact with claimants, attorneys, insureds, witnesses and others having pertinent information
  • Effectively and efficiently manage vendors and expenses
  • Timely analyze information in order to evaluate assigned claims to determine the extent of loss, taking into consideration contributory or comparative negligence. Assign medical or other experts to case and arrange for medical examinations when necessary
  • Effectively evaluate, negotiate and resolve claims within delegated authority utilizing the appropriate denials or releases
  • Provide required reports to claims, underwriting, reinsurance and actuarial on significant exposure cases
  • Report on all cases going to trial on a timely basis and attend portions of trials when warranted or where requested by management
  • Ensure proper referrals and timely updates to appropriate Reinsurer(s)
  • Ability to handle or oversee Extra-Contractual, EPLI, Social Services and E&O claims against the Company
  • Multi-State licensing with strong understanding of Medicare reporting & compliance preferred
  • Experience in complex coverage analysis and significant large loss evaluations
  • Superior communication and strategic negotiation and claim disposition skills along with proven problem-solving skills
  • Moderate proficiency with standard business-related software (including Microsoft Outlook, Work Excel, and PowerPoint
  • Sufficient keyboarding proficiency to enter data accurately and efficiently
  • 8+ Casualty claims handling experience (of those, a minimum of 5 years handling cases of a complex nature with a primary P&C carrier)
93

Claims Specialist Senior Resume Examples & Samples

  • Must have demonstrated core competence as a Claims Specialist Int or Claims Generalist Int negotiating injury claims
  • Ability to quickly build rapport and successfully effect settlements
  • Bachelor's degree or a minimum of 6-10 years of relevant work experience and/or postsecondary education
  • Company-provided Cell Phone - during work hours
94

Senior Claims Specialist Resume Examples & Samples

  • Provide first-line assistance for member's questions relating to post-service coverage of medical treatment or services which includes researching and resolving benefit claims issues, billing discrepancies, coding errors, insurance claims processing issues, and educating members on the components of their benefit plan coverage which ensuring adherence to corporate and department policies and procedures
  • Research plan information and identify where there may be conflicting information which may include escalating to supervisor or other levels of management for clarification and assistance
  • Assist members with setting up payment arrangements and discounts which may include reaching out to healthcare providers to determine payment options
  • Handle cases that require complex coordination of benefits issues among several carriers (e.g., motor vehicle, Medicaid, Medicare due to disability, disability administrator, etc.)
  • Participate in the development of policies and procedures to improve department workflow and the claims process ensuring proper documentation
  • Minimum of five years customer service, healthcare, or claims experience required
  • COBRA
  • Medicare A, B, MediGap, Supplement plans, Medicare Advantage, Medicare Part D plans
  • High deductible health plans including Health Reimbursement Accounts (HRAs) and Health Saving Accounts (HSAs)
  • Flex Spending Accounts (FSA) , including limited FSAs
  • Coordination of benefits and which plan is primary - simple and complex cases (commercial plans, Medicare plans)
  • Summary Plan Documents (SPDs) and Certificates of Coverage (COCs)
  • Government programs, resources and legislation and mandates including but not limited to Affordable Care Act, FMLA, Medicaid, CHIP
  • Group Health Plans (fully insured and self-insured)
  • Pharmacy benefits including injectable medications
  • Individual Health Plans and Exchanges plans
95

Claims Specialist Resume Examples & Samples

  • Optimizes Work Processes
  • Instills trust
  • Cultivates innovation
  • Decision quality
  • Collaborates
  • Minimum 1-2 years post-secondary education or equivalent experience [Minimum 1-3 years disability, workers comp, or waiver of premium claims experience]
  • Knowledge of diagnosis and procedure codes, general medical terminology, and disability duration guidelines
  • Excellent verbal and written communication skills including professional telephone skills
  • Microsoft Office Suite
  • Ability to multi-task and prioritize workload in a workflow environment
  • Business Acumen: Appreciation and understanding of the financial services industry in order to make sound business decisions
96

Life Claims Specialist Resume Examples & Samples

  • 1+ years claims experience (life insurance claims is preferred)
  • Proven analytical and problem solving skills and attention to detail
  • High level of compassion and commitment to customer service
  • Learning Agility: Openness to new ways of thinking and acquiring new skills to retain a competitive advantage
97

Senior Claims Specialist Resume Examples & Samples

  • Identifying, monitoring and reporting on emerging liability and coverage trends
  • Broad surplus claims experience: minimum of 5 years of experience managing claims. Experience in the handling and management of general liability, contracting, premises liability, products liability, and excess liability claims preferred
  • Collaborative approach: Develop productive working relationships with insured, brokers, claim handlers, Underwriters and legal counsel. Seek input from others as needed to achieve the best result possible. Capable of working and collaborating with a virtual team
  • Possession of state adjuster licenses is preferred. Insurance designation(s) (CPCU, AIC, ARM) preferred
98

Claims Specialist Resume Examples & Samples

  • Minimum of 3 (or more) years of solid experience handling Professional Liability claims to include Lawyers and Accountants E&O, Insurance Agent E&O, Miscellaneous E&O, and other specialty areas preferred
  • Strong knowledge of the insurance industry, claims, and the insurance environment
  • Possesses a functional and developing knowledge of multi-state legal statutes and procedures
  • Law degree preferred
  • Professional Designations preferred
99

Senior Claims Specialist Resume Examples & Samples

  • Helps develop and execute the strategies for large accounts to help identify coverage based on applicable policies, manage claims and overall programs in conjunction with WTW safety and service teams
  • Directly handles clients as primary consultant including complex consulting and strategy
  • Maintain direct relationships with key clients
  • Manage the appropriate level of resources for your clients
  • Participate in strategic large client meetings as required
  • Extensive experience of handling multi-line claims with focus on general liability claims of a complex nature. Experience with additional lines including property, construction defect, and/or workers’ compensation claims would be a benefit
  • High School diploma and college degree required
  • Travel required, primarily within Denver, Phoenix, and California
100

Priority Claims Specialist Resume Examples & Samples

  • Attention to detail with the ability to quickly identify trends
  • Working knowledge of the Medicare audit, appeals, reimbursement, Local Coverage Determinations (LCDs), and policy articles
  • Working knowledge of medical terminology
  • Self-starter / take initiative to proactively resolve problems
  • Strong sense of personal accountability to meet deadlines
  • Working knowledge of MS Office suite programs
  • Working knowledge of Electronic Health Records (EHR); such as, OPS and NextGen
  • Demonstrated ability to pull data and migrate into online records management systems such as OnBase
  • Demonstrate high ethical standards regarding confidential patient and billing information
101

Claims Specialist Resume Examples & Samples

  • Process detail billing from provider for complete required data elements and assure all data is captured correctly in the payment system before releasing payment
  • Accurately assign pay/deny codes and verify the associated charges for services provided
  • Understand contractual expectations with network providers to assure compliance with terms and expectations
  • Maintain confidentiality at all times whether in reference to confidential information or as it relates to medical information for specific patients
  • Create reports and meet deadlines for reimbursements
  • Identify any inconsistent billing practice or methodology for further review. Forward identified transports to audit area for further investigation
  • Meet daily productivity quotas on a consistent basis
  • Demonstrated familiarity with Medicaid terminology and services
  • Previous experience in claims processing preferred
  • Must be proficient with Microsoft Office software
  • Must type 30 wpm
  • Must operate 10-key calculator by touch
  • Must have effective oral, written and interpersonal communication skills
102

Claims Specialist Resume Examples & Samples

  • Daily claims processing
  • Understanding of Section 125 administrative processes and procedures
  • Understanding of HIPAA and Privacy Regulations
  • 1Cloud, Excel and OnBase experience preferred
  • Meets daily deadlines consistently
  • Must take initiative in jobs performed
  • Flexibility/ adaptability
103

Claims Specialist Resume Examples & Samples

  • Sets activities, reserves and authorizes payments within scope of authority. Ensures issuance of disbursements while managing loss costs and expenses
  • Coordinates and performs investigations and evaluates claims and suits through contact with insureds, claimants, business partners, witnesses and experts. Seeks early resolution opportunities. Identifies files that have potential fraud and refers to SIU
  • Utilizes negotiation skills to develop complex settlement packages
  • Identifies claims with third party recovery potential and coordinates with subrogation/salvage unit
  • Partners with attorneys, account representatives, agents, underwriters, doctors, nurse case managers and insureds to develop a focused strategy for timely and cost effective resolution of more complex claims
  • Strong interpersonal, communication and negotiation skills. Ability to effectively interact with all levels of CNA's internal and external business partners
  • Ability to exercise independent judgement and make critical business decisions effectively assessing the merits of claims as well as evaluating claims based on a cost benefit analysis
  • Typically a minimum three to five years claims experience
104

Senior LTD Claims Specialist Resume Examples & Samples

  • Independently assess, analyze and render appropriate claim decisions pursuant to certificates on most complex claims
  • Clarify functional capacity through independent problem solving measures and discretion (gathering medical, vocational, and other information, efficient use of resources, and action planning) sufficient to determine initial and ongoing liability
  • Communicate clearly and concisely to influence return to work, discuss terms of the certificate, and the basis for payment/non-payment
  • Communicate with a variety of constituents (for example, claimants, doctors, nurses, employers, and attorneys) to gather information relevant to assessing, analyzing and rendering decisions based on the provisions of the policy and their own discretion, with limited guidance by supervisory personnel
  • Provide mentoring and/or coaching to less experienced team members, and handle more complex claims
  • As the sole owner of the LTD claim, determine return to work potential and strategy, identify a likely claim progression based on the facts of the claim and take action on their own assessment of the claim
  • 5+ years’ long term disability claims experience
  • Ability to prioritize and maintain quality
105

Claims Specialist Senior Resume Examples & Samples

  • Confirm coverage and policy information
  • Initially establish and maintain proper loss reserve, and negotiate loss settlements
  • Conduct in-house investigation by taking recorded statements, ordering police reports, reviewing repair estimates, securing medical reports, etc. Attend necessary meetings or appearances on assigned claims as directed or approved by Supervisor
  • Keep Supervisor advised of significant developments in claims. Prepare required reports and other notices in a timely manner
  • Be familiar with and comply with all applicable provisions of Tokio Marine's Employee Handbook
  • Answer correspondence and inquiries promptly from brokers/agents, insureds, claimants, attorneys, outside vendors, TMM-employees, etc
  • Perform special projects and other duties as may be assigned
  • Four to five years of experience
  • Knowledge of tort law, motor vehicle law, basic reinsurance, and coding related to claims technical matters
  • Ability to negotiate settlement of claims in a timely and reasonable fashion
106

Claims Specialist Resume Examples & Samples

  • Reconcile claims filed to payments received on Investor and Mortgage insurance claims. Prepare claim payment reconciliation to ensure full payment is received
  • Determine root cause of curtailed items and determine whether supplemental claim, client expense or loss has been incurred
  • Update the system with pending, submitted, withdrawn and paid claim information
  • Stress Management: The ability to keep functioning effectively when under pressure and maintain self-control in the face of hostility or provocation
107

Claims Specialist Resume Examples & Samples

  • Helping to implement the general corporate strategy and adapt it to his/her specific work domain
  • Keeping professional knowledge permanently up to date in order to anticipate what is coming and to
  • Follow-up on trends in the health care market
  • Active language knowledge of at least English and French
  • An extra language may be required, depending on the contracts assigned
  • At least 5 years of relevant work experience
  • Solid knowledge of administrative processes and customer services
  • Advanced knowledge of Microsoft office - and own IT- applications
  • Sociable: correct, professional and at ease in contact with different stake holders (clients, colleagues,
  • Team members, superiors, …)
  • Organisational skills: is able to plan, prioritise and coordinate tasks in an efficient way
  • Accurate: accurately controls own work and work of team members in order to achieve faultless administration
  • Analytical: is able to invent, set up and evaluate procedures to achieve the fixed targets
  • Decisive: is able to set clear targets for him/herself and appropriate targets for his/her team members and takes decisions autonomously
  • Empathic: is able to imagine oneself in the situation of or see the point of view of others
  • Managerial skills: knows how to motivate and evaluate a team, how to delegate tasks in an efficient way and how to stimulate cooperation in his/her own team and also with other units and departments
  • Independent: is able to work independently
  • Pro-active and problem-solving: anticipates in a creative way expectations of clients and expectations of the company and formulates proposals for appropriate improvement
  • Writing skills: conveying clear and to-the-point messages in the appropriate style
  • Responsible: takes care that the assigned tasks are followed up in a dutiful, timely and correct way
  • Discipline: pays attention to procedures, agreements and document flows
  • Efficient: finds a good balance between quality and quantity
  • Discreet: works discreetly with confidential (medical) information
108

Claims Specialist Resume Examples & Samples

  • Manage claims to appropriate closure while providing excellent customer service
  • Provide timely and accurate claims administration in keeping with client contracts and within applicable state laws
  • Respond to requests by mail or telephone from clients, internal staff, claimants, medical providers and adjusters
  • Adhere to high standards of professional conduct while providing superior claims service
  • Responsible for conducting employee, client and internal contact on all assigned claims
  • Work closely with business units to gather claim related information
  • Review new claim reports and determine the most effective handling procedure for each individual claim
  • Assist with preparation of files for suit, trial, or subrogation
  • Respond to all voicemail, e-mail, and faxes associated with assigned claims
  • Maintain an effective diary on all assigned claims, to include departmental and personal calendars
  • Maintain current knowledge of assigned insurance lines and court decisions which may impact the claims function
  • Submit First Report of Injury to the carrier and/or TPA with appropriate tracking designations and in keeping with deadlines
  • Identify potential fraud through validation of claims information
  • Make outbound calls to carrier, injured employee & health care providers to obtain work status and case notes
  • Receive and respond to inbound calls from clients, claimants, adjusters and System One staff
109

Claims Specialist Resume Examples & Samples

  • Process, review, and adjudicate claims in an accurate and timely manner
  • Review files for accuracy, file completeness, and eli