Claims Examiner Resume Sample
Tito Lindgren
66973 Milton Islands,
New York,
NY
+1 (555) 601 2868
Work Experience
Senior Claims Examiner
01/2018
-
PRESENT
Chicago, IL
- Investigates, evaluates, interpreters and makes determination of long-term disability claims with sound and impartial claim judgments, using appropriate duration guidelines when necessary
- Processes increasingly complex assigned claims for payment or denial in accordance with established procedures and guidelines, in a timely manner and meeting departmental quality/production standards
- Prioritizes and balances claims in an efficient manner while maintaining productivity, quality, and time service requirements, as outlined by senior management
- Provides routine responses and a diverse range of information to junior team members’ questions to support organizational capabilities
- Investigates and determines the outcome of disability claims with sound and impartial judgement using available resources such as vocational and medical information
- Reviews increasingly complex submitted claim information for payment and ensures the accuracy and completeness of submitted claim information
- Light physical effort (lift up to 10lbs). Regularly needs to be able to bend, stoop and reach to file
- Process complex claims in various queues. Conduct research and investigation into missing information, make phone calls to providers, access resource materials and support files in order to process and adjudicate claims timely and accurately
Claims Examiner
03/2011
-
11/2017
Detroit, MI
- Diary compliance (new mail & CMR’s), verify, analyze and appropriately establish reserves based on lifetime exposure. (40%)
- University / college graduate or equivalent working experience
- Professional insurance qualification such as ANZIIF (Senior Associate) or ACII is an advantage
- Olid experience in handling CGL claims and common law claims
- Handle litigation case independently
- Make accurate judgments on liability and assessments of loss values
- Providing excellent customer service, support and quality work product to clients
Junior Claims Examiner
04/2004
-
01/2011
San Francisco, CA
- Resolve complex pended claims, duplicate claims and adjustments
- Process claims, involving communications with participating plans and/or Service Units. Resolve various issues
- Research and identify other insurance, Medicare, Medicaid and update patient file as needed
- Coordinate benefits; request explanation of benefits as needed
- Maintain a working understanding of medical terminology and CPT, HCPCS, and ICD9 coding
- Read appropriate files in IMAGE and apply information to claims as needed using the Financial Suspense System (FSS)
- Assist with testing system changes and enhancements
- PC Skills (Word, Excel and E-Mail)
- Monitor treatment in accordance with settlement and UR (35%)
Education
University of California, San Diego
2000 - 2004
Bachelor's Degree in Related Area Required
Professional Skills
- Strong negotiation skills, decision making and problem solving skills required. Experience with first-party coverage interpretation
- Strong coverage analysis skills and experience handling declaratory judgement actions
- Computer proficient - accurate keying skills and Microsoft office skills, specifically Excel and Word
- Strong PC skills required, Microsoft Windows experience highly desired
- Excellent listening, communication, verbal, and writing (documentation) skills
- Excellent customer service, problem solving, organizational, and research skills
- Proven skills in positive and effective interactions with challenging customers
How to write Claims Examiner Resume
Claims Examiner role is responsible for computer, analytical, customer, microsoft, organizational, basic, interpersonal, windows, research, training.
To write great resume for claims examiner job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Claims Examiner Resume
The section contact information is important in your claims examiner 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 Claims Examiner Resume
The section work experience is an essential part of your claims examiner 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 claims examiner responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular claims examiner position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Claims Examiner resume experience can include:
- Excellent organizational skills, interpersonal and communication skills
- Experience as a Claims Examiner with strong organizational and mathematical skills required
- Demonstrated effective communication and personal computer skills
- Excellent written and oral communication and interpersonal skills with the ability to demonstrate professionalism, diplomacy
- Good understanding/knowledge of policy language skills enabling accurate and consistent policy wording interpretation
- Experience in effectively following up on recommendations from technical claims audits and continuous claim handling improvements
Education on a Claims Examiner Resume
Make sure to make education a priority on your claims examiner resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your claims examiner 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 Claims Examiner Resume
When listing skills on your claims examiner 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 claims examiner skills:
- Good written (grammar and punctuation) and verbal communication skills including the ability to communicate clearly and being a good listener via the telephone
- Effective interpersonal and listening skills to build solid relationships inside and outside the enterprise
- Demonstrate and utilize effective problem solving skills
- Experience in effectively meeting/exceeding individual and team goals
- Process excellent oral and written communication, computer skills in a mainframe setting
- Excellent oral and written communication skills
List of Typical Experience For a Claims Examiner Resume
1
Experience For Senior Claims Examiner Resume
- Strong Computer Skills-Microsoft Office-specifically strong excel experience
- Excellent follow up skills and the ability to meet deadlines
- Strong verbal/written telephone communication skills
- Strong PC skills ( Windows based environment)
- Solid analytical and basic math skills
- Basic leadership skills to mentor less experienced personnel on own or other teams
2
Experience For Complex Claims Examiner Resume
- Effective verbal, written and interpersonal communications skills in a professional manner
- Olid experience in claims handling
- Commercial property and/or catastrophe claims examination processing experience or related insurance experience
- Organization skills Detail oriented
- Effectively communicate with External and Internal teams to resolve claims issues
- Hands-on experience and strong aptitude with Microsoft Excel, PowerPoint and Word
- Customer service/prior claims or related experience is a positive
3
Experience For Workers Compensation Claims Examiner Resume
- Communication skills to interact and present findings to team members and other employees
- BSN + 3 yrs related experience, or MSN + 1 yr related experience
- Intermediate skills with computer and Windows PC applications
- Analyzing and processing insurance claims transactions that require a strong understanding of Claims processing
- Maintaining a solid working knowledge of the insurance industry and of all products, services and processes performed by the team
4
Experience For Life Claims Examiner Resume
- Some claim’s examining experience required whether from examining or answering calls related to claims
- Strong personal work ethics with commitment to build credibility and trust. This includes maintaining confidentiality and exercising discretion and tact
- Ability to be a team player, work professionally, collaborate, in addition to building and maintaining effective relationships for results
- Weighs the costs and benefits of going to trial versus entering into a settlement and chooses the most effective option
- Experience in role that required understanding and interpreting complex documents such as medical records and legal contracts
- One year claims processing or related experience required
- Excellent knowledge of medical terminology, ICD-9 and CPT-4 coding
- Develops effective working relationships with outside vendors and ensures professional client relationships
5
Experience For Junior Claims Examiner Resume
- Utilize the QNXT claims processing module in an effective and efficient manner to process claims
- ) of experience in a role that required a focus on quality including attention to detail, accuracy, and accountability for your work product
- Experience reviewing legal and medical documents
- Administers indemnity and medical benefits for valid Workers’ Compensation claims
- Determines claim compensability based on witness statements and other evidence
- Maintain confidentiality; excellent judgement and discretion
- Studies reports and similar claims to determine validity of the claim
- Up to 2 years experience in claims
- Provide Excellent Customer Service to all external and internal stakeholders
6
Experience For Healthcare Claims Examiner Resume
- Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines
- Participate in team meetings and provide ideas, suggestions and feedback to promote effective program management
- Review daily validation and operational reports to manage case load
- Prioritize, multitask and manage claims assignment within department goals and regulatory compliance and with minimal supervision
- Excellent knowledge of HMO, PPO, and POS plans
- Excellent knowledge of coordination of benefits, subrogation, and Medicare
- Validating payment periods, providing necessary follow up
- Or more claims examining experience required
- Experience adjudicating Workers Compensation claims under Nevada jurisdiction
7
Experience For Complex Claims Examiner, Personal Lines Resume
- Experience processing lost time claims
- Experience handling California Workers' Compensation Claims
- Experience handling California workers' compensation claims
- Experience using Microsoft Office programs, especially Excel, Word, PowerPoint, and Access
- WC Claims handling experience in multiple jurisdictions
- Experience managing claims
- Claims processing experience - Medicaid, Commercial, Medicare Advantage or Tricare
- 1 – 3 yrs of absence management claims experience including familiarity with US Federal and State Leave of Absence Laws
8
Experience For Senior PW Claims Examiner Resume
- Prioritize tasks from most important to least and use active verbs to start your sentences
- A valid California adjusters’ license
- Experience with Workers Compensation Claims required
- Experience with self-insured employer is desirable
- Experience in P&C insurance
- Previous experience in the insurance industry helpful but not required. Attain ANFI certification within one (1) year of hire
- Experience on PC or CRT
- Experience with claims and/or other related claims processes
- Up to 2 years Claims experience
9
Experience For Claims Examiner Trainee Resume
- Experience in Insurance Claims
- Claims examiner experience
- 3 1/2-5 years of related, hands on experience
- Medicare/Medicaid Claims experience
- Experience with Commercial Auto and Property, Motor Truck Cargo, and Casualty
- Experience as a Case Manager with the VIC Workers Compensation Scheme, ideally in Long Term Management
- Work under pressure with a strong sense of urgency to meet deadlines, performance guarantees, and customer inquiries
- Experience processing medical, dental, prescription or mental health claims
10
Experience For Associate Health Claims Examiner Resume
- Multi-line brokerage claims experience
- Approving, pending, or denying payment according to the accepted coverage guidelines
- Assisting team manager in managing team administrative works and preparing reports to internal stakeholders when and if necessary
- Updating, manually processing, adjusting claims and/or records as appropriate
- Communicating with the Team Leader, Claims Adjusters, Brokers, placing Brokers, Managing Agents and (re)insured’s
- Reviewing the coverage and damage on each claim utilizing Best Practices as a guide
List of Typical Skills For a Claims Examiner Resume
1
Skills For Senior Claims Examiner Resume
- Effective advanced interpersonal skills to effectively interact with all levels of interna and external clients
- Good typing/computer and time management skills
- Excellent 10-key and computer skills
- Demonstrated competency in medical research and internet research skills
- Share continual responsibility and ensuring calls are handled efficiently and effectively
- Three to five years commercial property and/or catastrophe claims examination processing experience or related insurance experience
2
Skills For Complex Claims Examiner Resume
- Computer skills including Word, Excel, PowerPoint, Access, Outlook, RMIS, Workflow systems, and Internet research
- Computer skills including windows based environment
- Interpersonal skills for interacting with team members and other employees
- Computer skills including Windows, Word & Excel
- Experience with Xchanging processes a strong advantage
- Above average written and keying skills
3
Skills For Workers Compensation Claims Examiner Resume
- 10KEY data entry skills very importanct
- Experience with Healthcare / Medical Claims experience
- Contribute effectively within a team environment and to be a team player
- Prioritize multiple tasks, meet deadlines and provide excellent customer service
- Exceptional analytical/ technical skills
4
Skills For Life Claims Examiner Resume
- Effectively advise and counsel customers on claim status while providing prompt and exemplary customer service
- One to three years of relevant experience, or a combination of education and experience
- Experience working in premium billing, COBRA administration, flexible spending and disability processing
- Comprehensive experience in dealing with high net worth domestic insurance claims including house, contents and private collections
- 2) two-years work experience as a claims examiner independently analyzing and processing non-routine complex medical claims at another employer
- Claim processing or medical billing experience in a managed care environment or physician's office
5
Skills For Junior Claims Examiner Resume
- Experience processing and adjudicating simple to complex claims
- Experience processing and adjudicating claims for commercial health insurance companies, managed care organizations or other healthcare related field
- Maintain good working relationship during all contacts with clients
- No fault background with coding experience
- Property claims adjusting experience
- Experience in claims examining
- Experience working with claims adjudication in the health care industry, preferably HMO
- Homeowner's 1st Party Claims Adjusting experience
6
Skills For Healthcare Claims Examiner Resume
- Homeowner's Claim Handling Field experience
- Prioritizes assigned claims according to regulatory timelines
- Medical Terminology and/or coding experience is highly desirable
- Skill in performing manual computer assisted legal research
- Previous medical or vision claims processing experience
7
Skills For Complex Claims Examiner, Personal Lines Resume
- Experience working with Electronic Data Systems
- Healthcare benefits or billing experience
- Knowledge of tort law, health care systems, risk management techniques, and medical malpractice claims handling experience
- Experience working with Medicare, Medicaid, Affordable Act, Commercial, Small/Large Group and/or Pharmaceutical Benefits Management
- Health care claims processing experience
- Experience of Professional claims processing
- Previous medical claims processing experience
- A strong knowledge of legal and regulatory requirements for the handling of financial lines claims in Australia
8
Skills For Senior PW Claims Examiner Resume
- Health care claims processing experience
- Experience handling customer support issues, ideally in an safety or claims environment
- Experience in handling litigation
- Experience adjudicating Workers Compensation claims
- Experience processing lost time claims
- Previous medical claims processing experience
- Experience identifying root cause claims adjudication process failures and ability to quantify departmental impact
9
Skills For Claims Examiner Trainee Resume
- Experience with the investigation, determination and reporting of claims processes
- Experience working with quality metrics and analysis techniques highly desirable
- Apply principles of legal thinking to define problems, collect data, establish facts and draw valid conclusions
- Two (2) years experience in processing medical claims, knowledge of ICD-9, CPT-4, HCPCs, and ADA guidelines, medical terminology, fee schedules and contacts
- Two or more years HMO claims processing experience required in a managed care environment
10
Skills For Associate Health Claims Examiner Resume
- Solid working knowledge of insurances- PPO, EPO, HMO, POS, Medicare, Etc
- Two or more years experience in PMG/IPA setting within the last three years or any combination of education
- Medical claims examining experience
- Experience in processing different types of claims
- Experience processing medical, dental, prescription or mental health claims
List of Typical Responsibilities For a Claims Examiner Resume
1
Responsibilities For Senior Claims Examiner Resume
- Evaluates and analyzes documentation thoroughly to determine claim processing according to policy provisions and state regulations with moderate authority limits
- Evaluates and analyzes documentation thoroughly to determine claim processing according to policy/certificate provisions and state regulations with limited authority limits
- Excellent negotiation skills and the ability to make fact based decisions in a timely manner
- Has effective analytical and interpretive skills
- Effective communication management skills
- Possesses good time management and organizational skills
- Demonstrates understanding of team and enterprise goals by effectively
- Customer-oriented and effective communication skills
- Proficient in typing and computer skills
2
Responsibilities For Complex Claims Examiner Resume
- Excellent knowledge of HMO, PPO, and POS plans. Excellent knowledge of coordination of benefits, subrogation, and Medicare
- Experience Required: 3-5 years' experience in insurance/claims required
- Basic computer skills and basic knowledge of Microsoft Office software required
- Conducts investigations of claims by interviewing claimants and witnesses, obtaining official reports, and by comparing claim information with evidence
- Experience in determining contractual obligations, coverage analyses, and investigations
3
Responsibilities For Workers Compensation Claims Examiner Resume
- Handle multiple and conflicting priorities in a fast paced environment required
- Utilize effective communication to obtain information both verbally and in writing, and provide information to the claimant and employer
- Have strong decision-making ability
- Experience adjusting lower level complexity Personal Accident and Travel claims
- Experience calculating financial claims or benefits
- Up to 2 years’ experience in claims
- Manage multiple and changing priorities in a fast paced environment
- Experience in management of occupational claims and administration of benefits
4
Responsibilities For Life Claims Examiner Resume
- Medical malpractice claims and litigation experience required
- Maintain excellent relationship with clients
- Focus on cost effective delivery of benefits and resolution of cases. Develop and documents plan to resolve cases
- Assist with developing and participating in effective training and documentation
- Strong understanding of the group life insurance industry
- Examine titles to property to determine validity and act as company agent in transactions with property owners
- Experience in workers' compensation claims or related field
5
Responsibilities For Junior Claims Examiner Resume
- Primary and/or Excess Casualty Claims experience
- Experience in workers’ compensation field required
- Commercial Claims with a strong knowledge of Property
- Workers' compensation, disability management or closely related experience. Required
- One year experience in a medical insurance environment
- Good command of English preferable
- Verifying member eligibility, benefit coverage and researching or applying authorizations
- Tracking and documenting work loss and work restriction days
- Supporting insurance company client by processing insurance transactions. Add, delete, modify, test data in systems based on client requests
6
Responsibilities For Healthcare Claims Examiner Resume
- Applying Insurance domain knowledge, theoretical concepts etc. to undertake problem solving
- Complying with company regulations regarding HIPAA, confidentiality, and private health information
- Meeting with clients to discuss reserve adequacy and proper claims handling
- Assisting with marketing and sales of claims management services to prospective new accounts
- Communicating and strategizing with insureds, carriers, TPAs, adjusters, attorneys, etc. to settlement
- Maintaining diary of files for follow-up and documenting all follow-ups in database
- Creating and maintain claim trending, lag time reports, and loss analysis of complex claims
- Reviewing and evaluating claims for information on which to base payment
- Documenting claims files and properly coding claim activity
7
Responsibilities For Complex Claims Examiner, Personal Lines Resume
- Communicating claim action/processing with claimant and agent
- Troubleshooting all claims with potential third party liability, i.e. subrogation, COB, or MVA and stop loss claims and potential stop loss files
- Adjudicating claims based on insurance and provider contracts
- Ensuring accurate and timely completion of transactions to meet or exceed client Service Level Agreements (SLA)
- Working knowledge of ISO policies
- Working knowledge with Xactimate
- Implementing medical & like cost management strategies on claims
- Contributing to maintenance of best practice procedures for financial lines intermediate Complex claims, consistent with global best practice
- Ensuring adherence to best practice procedures for financial lines complex claims, consistent with global best practice
8
Responsibilities For Senior PW Claims Examiner Resume
- Handling higher level of complex claims within authority limits
- Contributing to maintenance of best practice procedures for Casualty Complex claims, consistent with global best practice
- Contributing to maintenance of best practice procedures for Travel Complex claims, consistent with global best practice
- Soliciting and coordinating required information between Management staff and team members to complete daily assignments
- Examining and Processing of Claims
- Demonstrating technical claims competence for handling high to moderate complexity complex claims
9
Responsibilities For Claims Examiner Trainee Resume
- Liaising with different internal departments in data enhancement project for further analysis
- Working knowledge of McNet/Batch errors
- Preparing and/or initiating a variety of correspondence and documents to respond to inquiries/problems
- Maintaining inquiry tracking appropriately
- Utilizing appropriate reference materials to research information, respond to, and resolve problems
- Preparing reports and/or logs, as necessary
- Monitor TPA’s compliance with claim handling procedures including: nurse case management, return to work, counsel assignments, and reserving
- Maintains professional and technical knowledge by attending continuing education opportunities (workshops, fraud training, claims conferences, etc.)
- Provide support for fellow team members by providing appropriate coaching, counseling, direction and resolution
10
Responsibilities For Associate Health Claims Examiner Resume
- Assist manager with daily operation of claims processing to include development, analysis and implementation of staffing and training
- Complete the manual pricing of claims according to provider contracts and other claims pricing references
- Complete more complex claims processing tasks including: claim adjustments, coordinating benefits with secondary carrier, claim reversals, etc
- Primarily responsible for Mobile Home, Dwelling (including Condo Unit), Small and Large Commercial Claims, RCBAP up to Authority, and all levels of ICC
- Maintain working knowledge of all company and services pertaining to business segment
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