Claim Specialist Resume Sample
Jeffrey Shanahan
503 Weimann Canyon,
Boston,
MA
+1 (555) 859 3378
Work Experience
Claim Specialist
06/2017
-
PRESENT
Philadelphia, PA
- Audit select claim files for TPA compliance with Aramark’s account instructions and the TPAs best practices
- Communicates proactive resolution strategies to the TPA consistent with Aramark’s internal settlement/disposition philosophy
- Litigation Process - Develops and maintains effective business relationships with counsel. Responsible for the appropriate assignment of counsel on claim files, monitoring counsel’s work product, and partnering with counsel to handle litigation claims in the most efficient manner
- Reserving/Reporting - In accordance with Westfield’s reserving philosophy, establishes and reviews proper reserves for each claim based upon thorough investigation, evaluation, and experience. Completes appropriate reports so that the current status of the claim is clearly documented at all times
- Assists in developing training and analysis of pilot programs. Develop and lead training sessions to ensure claim team members’ understanding of state compliance requirements, regulatory changes, and vendor changes and reinforce department standards on compliance goals and quality claim management
- Assists in developing training and analysis of pilot programs. Develop and lead training sessions to ensure claim team members’ understanding of state compliance requirements, regulatory changes, vendor changes and reinforce department standards on compliance goals and quality claim management
- Experience in personal lines injury claim settlements demonstrating expert knowledge
- Utilize advanced technical knowledge to audit auto material damage claims to ensure compliance and quality standards are met. Ensure state and internal compliance and quality is adhered to and requirements are met on a claim file. Responsible for quantifying potential indemnity and expense leakage on auto material damage claims and for coaching representatives on sound claim handling practices
Casualty Litigation Claim Specialist
07/2013
-
03/2017
New York, NY
- Experience in personal lines material damage claim settlements demonstrating expert knowledge
- Handle and document incoming/outgoing claim calls
- Provide resolution to customer questions and educates them on the claim process
- Initiate and complete claim settlement transactions fitting the express claim criteria
- Deliver an unparalleled customer service experience to deliver on the claims promise
- Follow documented department claim procedures and requirements defined by claims good faith claim handling guidelines
- Handles escalated calls with complex problems
- Assist with procedure and policy documentation
- Proven/Demonstrated ability to work independently and prioritize requests, with minimal assistance from a manager
Property Insurance Claim Specialist
08/2006
-
06/2013
Phoenix, AZ
- Proven/Demonstrated interpersonal and customer service skills
- Proven/Demonstrated ability to empathize with customer
- Strong analytical, critical thinking, problem solving skills and decision making skills
- Proficiency in MS Office environment, Windows and Web applications
- Communicate directly with third parties and customers to request medical, employment or other information needed to make a claim decision
- Analyze information received in order to make an independent claim decision
- Provide a proactive customer service experience characterized by keeping all parties informed of the claim status, next steps and claim decision
- Manage pending caseload focused on disability management and duration control while managing individual productivity and service levels
- Actively engage in an inclusive team environment by participating in team meetings and team projects
Education
Rockhurst University
2002 - 2006
Bachelor's Degree in Management
Professional Skills
- Strong analytical, critical thinking, problem solving and independent decision making skills
- Excellent negotiation and advanced technical claim handling skills, including knowledge of coverage and tort laws
- Strong data entry and 10-key skills
- Strong computer and MS Office skills
- Demonstrated interpersonal and customer service skills
- Prior experience in handling of claims brought against municipalities/public entities
- Superior analytical ability and organizational skills
How to write Claim Specialist Resume
Claim Specialist role is responsible for compensation, litigation, customer, negotiation, insurance, medical, analytical, interpersonal, credit, database.
To write great resume for claim specialist job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Claim Specialist Resume
The section contact information is important in your claim specialist resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Claim Specialist Resume
The section work experience is an essential part of your claim specialist resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous claim specialist responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular claim specialist position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Claim Specialist resume experience can include:
- Assist in training and/or mentoring less experienced associates and specialists
- Consistently deliver a remarkable customer experience through handling claims involving injury
- Assist in training and/or mentoring less experienced team members
- Experience handling high-exposure general liability claims
- Experience handling litigated claims
- Experience negotiating with third parties
Education on a Claim Specialist Resume
Make sure to make education a priority on your claim specialist resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your claim specialist experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Claim Specialist Resume
When listing skills on your claim specialist resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical claim specialist skills:
- Utilizes effective verbal communication skills and demonstrates cognitive interviewing skills
- Demonstrated negotiation skills are required for achieving favorable claim settlements
- Effectively partners with coverage and defense counsel
- Experience in the handling of commercial auto/trucking matters
- Balance multiple issues of varying priorities across customers while driving timely claim dispositions
- Delivers a remarkable customer experience through handling claims involving injury
List of Typical Experience For a Claim Specialist Resume
1
Experience For Casualty Litigation Claim Specialist Resume
- Experience: 5-10 years, WC and Claims Management experience
- Consistently deliver a remarkable customer experience through handling property claims
- Develops strong understanding of evidentiary issues
- Provides guidance and assistance to less experienced adjusters and other functional areas
- Foster strong, collaborative partnerships with Claims Operations, and other TDI and TDBG Business Units. Represent TDI with industry stakeholders
- Insurance experience
2
Experience For Electronic Insurance Claim Specialist Resume
- Revenue Cycle experience
- Management experience in a claims environment
- Proactively manage the litigation process to ensure timely and cost effective claims resolution
- Explaining/handling less complex PIP/AB/MPC handling when appropriate
- Reporting to P&C claims
3
Experience For Property Insurance Claim Specialist Resume
- Developing and monitoring the audit process and queue for the review of parts and labor pricing to ensure Lowe’s is being accurately charged
- Participation in the new product development process by providing system requirements, claims input on policy wording, insurance applications, and underwriting
- Fulfill state licensing and continuing education requirements as applicable
- Recognizes and handles subrogation opportunities, updating all appropriate subrogation fields and prepares file for subrogation handling
- Fulfills state licensing and continuing education requirements, as applicable
4
Experience For PIP Field Claim Specialist Resume
- Arrangement of rental car and providing towing service (when appropriate)
- Recognizes and handles subrogation opportunities, updating all subrogation fields and moves file to subrogation for handling, when applicable
- Serves as a resource for local jurisdictional issues involving third-party loss handling
- Maintains awareness of Medicaid, CHIP and Insurance billing and coding guidelines
- Arrangement of rental car, providing towing service (when required), SIU (recognize potential fraud indicators) and Subrogation (recognize sub and salvage)
- Reconcile and balance required remittance to approved vendors for billing & payment Moderate
- Completes on-site inspection of property damage, prepares building repair estimates and issues claim settlement payments
- Scopes and/or secures inventory of damaged personal property, enters into contents estimating platform and issues claim settlement payment
- Documents the claim file according to the file documentation workflow and standard claim processes
5
Experience For Liability Claim Specialist Resume
- Learns and applies knowledge of state and federal laws, statutes and insurance regulations in claim handling
- Recognizes and handles retained salvage and monitors pending salvage sale items
- Completes all applicable training
- Applies knowledge of policies, procedures, laws, statutes and insurance regulations when determining coverage, liability, and property damage
- Confers with management regarding the retention of outside investigative agencies and external vendors
- Communicates with witnesses, agents, other insurance companies, repair shops, contractors, attorneys, and others in the course of conducting investigations
6
Experience For Senior Claim Specialist Resume
- Complete all applicable training
- Interacts with internal partners, agents, other insurance companies, vendors, contractors, and service providers in the course of conducting investigations
- Applies knowledge of policies, procedures, laws, statutes, and insurance regulations when determining coverage, liability, and damages
- Utilizes appropriate job aids, expertise and tools to accurately and consistently process the initial reception of claims according to standard claim processes
- Manage Billing Audit Log
7
Experience For Repair Svcs Claim Specialist Resume
- Ensures proper billing of all charges to patients, insurance companies and government agencies such as CHIP and Medicaid
- Ensures all appropriate data required for the tracking of errors and omissions related to claims are made available on a timely basis
- Serve as a resource to the team by assisting lower band claim representatives with moderate complexity claims, as needed
- Inform agents as needed during claims process
- Settle ongoing claims
- Successfully pass required exams or coursework
- Launch Technical Resolution PAC cases for claims that require escalated support
- Escalate customer issues within GE to drive permanent solutions and keep turbines online
- Compile complete claim documentation in a timely manner from our global operations teams
8
Experience For Complex Workers Compensation Technical Claim Specialist Resume
- Review issue to identify the liable carrier, root cause, liability regimeand potential exposure to ftn
- Maintain organized claim files
- Measure claim settlement turnaround time and performance
- Communicate with insurance vendors, customers, and ftn t&b associates to streamline operations and minimize risk
- Maintain database of all insurance policies and customer contracts on sharepoint and on shared drives. Follow up with vendors to ensure timely payment of claims
9
Experience For Wind Energy Warranty Claim Specialist Resume
- Excellent verbal and written communication skills are required for corresponding with clients about the disposition of claims. Excellent organization skills are required for maintaining claim files
- General knowledge of insurance and carrier liability limits is required
- Overseeing the Original Equipment Manufacturer claim reject queues to determine whether to negotiate with a vendor for direct payment of the Independent Service Provider or process and pay the Independent Service Provider through the Lowe’s process and funding
- Desired - Working knowledge of Navy Federal financial and credit transaction documentation processes
- Works toward the resolution of claims files, and attends arbitrations, mediations, dispositions or trials as necessary
- Investigate claim files to determine steps needed to complete the settlement of claims
- Investigates and maintains claims. Reviews and evaluates coverage and/or liability. Secures necessary information (i.e., reports, policies, appraisals, releases, statements or other documents) in the investigation of claims
- Navigate daily through several platforms to research and accurately finalize claim submissions
- Prioritize and coordinate influx of daily workload for claims processing, returned mail and out-going correspondence and e-mails to assure required turnaround time is met
10
Experience For Claim Specialist Resume
- Analyze claims for potential fraud by member or pharmacy
- Superior data entry proficiency
- Investigate, evaluate, and resolve claims of the highest complexity and severity
- Draft coverage position letters with minimal supervision
- Manage complex litigation; attend mediations, arbitrations, depositions, and trials as necessary
- Moderate knowledge of drugs and drug terminology used daily
List of Typical Skills For a Claim Specialist Resume
1
Skills For Casualty Litigation Claim Specialist Resume
- Years of working experience : 5 years or more
- Technical claim handling experience with high exposure claims
- Technical claim handling experience of bodily injury and property damage claims
- Experience handling litigated files
- Establish and maintain effective working relationships with patients, employees and insurance
- Strong knowledge of Medicare, Medicaid, CHIP, Managed Care, and Commercial carriers
- Intermediate level experience with Microsoft Office (Excel, Word, Outlook Email, etc.)
2
Skills For Electronic Insurance Claim Specialist Resume
- Experienced in Excess and Surplus lines coverage
- Pharmacy tech experience in a retail environment
- Personal Injury Protection (PIP) experience
- Distinguish potential causes and determine if claim is a valid warranty claim
- Desired - Experience as a licensed Insurance Agent
3
Skills For Property Insurance Claim Specialist Resume
- Leads the work of others (mentors, prioritizes, delegates and reviews assignments)
- Excess/Umbrella claims experience required
- Catastrophic injury claims experience required
- Advanced coverage analysis experience required
- Two years’ experience in P.B.M. environment is helpful but not required
- Retail pharmacy, customer service experience helpful but not required
- Maintains good interpersonal, customer service and communication with all team members
4
Skills For PIP Field Claim Specialist Resume
- Handling non-routine legal correspondence
- Understanding the life cycle of a claim
- Process claims according to client specific guidelines while identifying claims requiring exception handling
- Perform billing audits to ensure correct billing of insured files with required knowledge of all ftn billing platforms
- Maintain necessary adjuster licenses, including completing required continuing education
- Co-ordinate litigation activity with external counsel and TDBFG legal department, including reviewing pleadings, statements of claim and defense
- Represent TD Life on litigation claims matters including attending some examinations for discovery, mediation and trials
5
Skills For Liability Claim Specialist Resume
- Technical SME for the development of claims training contents and Coordinate and present ad hoc technical training
- Review / Approve / Reject warranty claims by assessing the nature of a failure against what the customer is asking for in the claim
- Manage pending caseload focused on medical payments management and duration control while managing individual productivity and service levels
- Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing
- Comply with applicable company procedures and policies, statutes, regulations, and other legal requirements governing claims handling
- 6 month - 2 years + medical claims processing
- Participate in creation, documentation and implementation of training and procedure manuals
- Provide technical expertise and guidance to support best in class claims handling
- Reduce risk by proactively identifying, and initiate mitigation of business risks
6
Skills For Senior Claim Specialist Resume
- Maintain a claims work split and provide guidance to, Claim analysts on handling all
- Assign appropriate reserves, managing reserve adequacy throughout life of the claim
- CA, UT, AZ, OR licensing recommended
- Knowledge of dentistry and understanding dental terminology
- Work independently and under pressure while handling multiple tasks simultaneously
- Works on moderate to highly complex assignments requiring specialized knowledge in breadth and / or depth within Professional Liability claims
- Accurate and timely processing of claims submitted by member, pharmacy or appropriate agency
- Adhere to strict HIPAA regulations especially when communicating to others outside of the company
- Determine when supplier recovery process is required and work with sourcing team to initiate the process
7
Skills For Repair Svcs Claim Specialist Resume
- Support Warranty cost reduction activity through trend analysis and creative thinking
- Negotiate / Communicate with varying levels & functions warranty dispositions
- Communicate claim status to clients verbally and in writing
- Assist with training programs for global associates
- Verify member submitted claims forms, member’s eligibility and pharmacy information and updating system information as needed
8
Skills For Complex Workers Compensation Technical Claim Specialist Resume
- Adhere to strict HIPAA regulations especially when communicating to others outside of Express Scripts
- Verify member submitted claims forms, member’s eligibility and pharmacy information is complete and accurate, updating system information as needed
- Verifies and evaluates damages, while properly managing expense
- Maintains timely, professional notes documenting claim activity
- Communicates loss prevention information to appropriate underwriting personnel
- Travels as needed, including some overnight and air travel
9
Skills For Wind Energy Warranty Claim Specialist Resume
- Maintain accurate and prompt follow-up on billing/payment issues Moderate
- Communicate with investors amended procedures during periods of declared disasters Moderate
- Analyze claim exposure and determine proper course of action to bring file to conclusion
- Handling complex indemnity workers' compensation claims
- Responsible for reporting audits of errors and omissions to office and operations daily
10
Skills For Claim Specialist Resume
- Answers questions from office staff in regards to billing
- Follow up with ECentral reporting to confirm completion of claims submission
- Conduct claim audits and Quality Assessments Reviews (QAR’s) and provide feedback and recommendations based on the results
- Monitor claim SLA’s and ensure timely corrective action is implemented
- Education : BS or more
- 4099 McEwen, Suite 650, Dallas TX 75244
- Instruct external counsel with input from TD Legal and Director
- Review claims where litigation is contemplated
List of Typical Responsibilities For a Claim Specialist Resume
1
Responsibilities For Casualty Litigation Claim Specialist Resume
- Conduct background investigations pertinent to claim by utilizing various internal and approved external sources including internet search queries
- Uses various electronic resources for claim handling
- Documents the claim file according to file documentation workflow and standard claim processes
- Knowledge of multi line insurance products and basic finance and accounting principles
- Internal Posting Dates: 10/11 - 10/24
- Applies knowledge of policies, procedures, laws, statutes and insurance regulations when determining property damage
2
Responsibilities For Electronic Insurance Claim Specialist Resume
- Arranges rental car and towing service (when appropriate)
- Oral or written communication with internal departments, members, pharmacies or agencies to resolve claim issues
- Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing. Analyze claims for potential fraud by member or pharmacy
- Maintain an average of 30 Commercial claims per hour (cph) or 35 Work Comp claims per hour (cph)
- Verifies policy coverage as applicable to the specific loss
- Investigates claims to determine coverage liability and damages
3
Responsibilities For Property Insurance Claim Specialist Resume
- Obtains recorded and/or signed statements
- Secures police reports and conducts investigations
- Identifies third party contribution. Able to instruct, monitor and work with outside adjusters and vendors
- Sets appropriates reserves within authority and makes recommendations for reserves in excess of personal authority
- Identifies specific reinsurance treaties, when applicable
- Obtain and process insurance claim checks for immediate release or remittance to restricted escrow account of the mortgage loan per investor guidelines Moderate
- Order inspection reports at appropriate intervals; review inspection results to authorize and process repair fund release Moderate
- Prepare accurate documentation and calculation of wire transfers for payment submissions to vendor ledger accounts Moderate
4
Responsibilities For PIP Field Claim Specialist Resume
- Apply funds to mortgage upon receipt of approved claim proceeds from Insurance company Moderate
- Develop and recommend enhancements to improve operational processes and procedures Basic
- Desired– Familiarity with NFCU mortgage products, services, programs, policies and procedures
- Contact claimants, clients, medical providers and attorneys
- Investigate accidents and determine compensability
- Attend file reviews, mediations and hearings
5
Responsibilities For Liability Claim Specialist Resume
- Ensure that files are handled within company guidelines
- Current State of Florida All-Lines Adjuster License
- Multitask in fast-pace environment
- Conducts self in accordance with South Texas Dental’s Employee Manual
- Examines auto/fire claims involving NICB Indicators of Fraud and determines if additional or specialized investigation is appropriate to move claim to resolution
- Recognizes NICB Indicators of Fraud, focuses on suspicious loss indicator resolution and follow up on inconsistencies discovered during the investigation of the claim
6
Responsibilities For Senior Claim Specialist Resume
- Investigates claims to resolve indicators of fraud and initiate payment or, if investigation determines the claim is without merit, resist payment of claim
- Develops and communicates recommendations with respect to claim resolution
- Serves as a liaison to the public, governmental entities, and law enforcement agencies on insurance fraud issues
- Conveys more complex information (coverage, decisions, outcomes, negotiations, etc.) to all appropriate parties, maintaining a professional demeanor in all situations
- Experience in complex litigation as well as insurance coverage pertaining to Primary CGL with emphasis on Owners Landlord and Tenant and Construction Injury Claims
- Resolves a large volume of claims in an in office environment through investigation, evaluation, negotiation, verification of coverage, legal liability and extent of damage to property
7
Responsibilities For Repair Svcs Claim Specialist Resume
- Examines claims submitted by insureds and/or third parties, or such claims referred from other claim units, to determine whether additional or specialized investigation is necessary for claim resolution
- Prepares and/or reviews property estimates and contents estimates in loss settlements
- Assists agents in the resolution of claims
- Develops and applies basic knowledge of property damage related issues to handle claims within approved level of authority
- Seeks guidance from claims management on coverage issues to determine appropriate course of action when needed
- Utilizes appropriate job aids, knowledge and tools to handle claims
- Collaborates with other claim segments and internal partners
- Reviews and confirms information gathered in initial contact and secures additional information as needed
- Secures and evaluates material samples
8
Responsibilities For Complex Workers Compensation Technical Claim Specialist Resume
- Provides claim information to stewardship claim specialist to assist in claim resolution
- Interprets and applies insurance contract provisions
- Communicates verbally and in writing with witnesses, agents, insurance companies, vendors, contractors, attorneys, and others in the course of conducting investigations
- Reconciles submitted estimates with State Farm estimate on property damage losses and issues replacement cost benefits payments
- Reconciles invoices and receipts submitted on personal property losses and issues payment for replacement cost benefits
- Works in partnership with and provides instruction to contents team
- Learns to recognize subrogation and salvage issues
- Learns and uses claims policies and procedures
9
Responsibilities For Wind Energy Warranty Claim Specialist Resume
- Handles non-routine claims and tasks independently
- Serves as a resource for other State Farm associates on claim related issues
- Recommends appropriate resolution of coverage issues to management
- Applies knowledge of policies, procedures, laws, statutes, and insurance regulations when determining coverage, liability, damages of injury (first and third party) and property damage
- Works in partnership with and provides instruction to claim associates
- Determines whether additional or specialized investigation is necessary for claim resolution
10
Responsibilities For Claim Specialist Resume
- Works with minimal supervision to recognize, investigate and resolve complex coverage, liability and damage issues
- Works with attorneys in the defense of lawsuits with management oversight
- Collaborate with internal partners and interface with external vendors
- Attends trials, mediations, depositions, if court ordered
- Prepares and/or reviews written or computerized estimates in loss settlements
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