The basic job description of a Claim Examiner is to review the settled insurance claims, determine if the amounts and settlements are in accordance with the company’s practice, and report about underpayment or overpayment. The most common duties listed on the Claim Examiner Resume include – reviewing claims to determine correctness of cost, checking application completeness and accuracy, inspecting property damage, evaluating damages, consulting with architects and accountants; examining statements and photographs, listening to audio and video surveillance, recording data and statement, negotiating with claimants, working with attorneys, and reviewing new life insurance applications to check for any serious illness.
Skills needed for this role include – a very good ability to understand written statements and paragraphs, logical and reasoning abilities to identify the strength and weakness of each and every application, strong communicating skills, negotiation skills to reconcile differences, the capability to use appropriate instructional methods and procedures and social perceptiveness. A college degree with relevant work experience is the common qualification among Claim Examiners.
Summary : Innovative professional with years of progressive experience within hotel sales industry. Competent at managing responsibilities in fast-paced, high-volume atmosphere Schedule flexible.
Skills : Amisys 6.0, AWD, Power Step, MHC.
Description :
Analyzed and managed complex or technically difficult claims by investigating and gathering information to determine the exposure on the claim.
Assessed the liability and resolves claims within an evaluation.
Negotiated settlement of claims within designated authority. Prepares necessary state fillings within statutory limits.
Calculated and assigned timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
Calculated and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level.
Managed the litigation process; ensures timely and cost-effective claims resolution.
Coordinated vendor referrals for additional investigation and/or litigation management.
Experience
7-10 Years
Level
Management
Education
Diploma
Claim Examiner III Resume
Summary : To apply skills as a self-motivated, high-energy professional, with a rich functional and technical background in the insurance industry that allows to use those skills and experience to better the company.
Skills : Facet, Exp, Maces, MS-Excel.
Description :
Worked as an Administrative Assistant, Claim Examiner, Temporary Claim Supervisor, Trainer and Hearing Representative.
Expertise was with Michigan Workers' Compensation claims.
Duties included claim management, making decisions on compensability, jurisdictional issues, and litigation plans of action, third party investigations.
Worked closely with the Michigan Second Injury Fund to obtain appropriate reimbursement.
Participated in completing technical details such as coding for the NCCI and reserving recommendations.
Participated in interviewing and hiring of additional staff in our Grand Rapids location while dedicated to the Steelcase account.
Assigned as the temporary supervisor during the regular supervisor's absence and trained and managed new employees.
Experience
10+ Years
Level
Senior
Education
Liberal Arts
Claim Examiner I Resume
Objective : Recent college graduate with information system knowledge. Professional, detail-oriented network administrator motivated to drive projects from start to finish as part of a dynamic team.
Skills : Microsoft Office, WordPoint.
Description :
Performed qualitative analysis of records to ensure accuracy, internal consistency and correlation of recorded data.
Researched questions and concerns from providers and provided detailed responses.
Accurately selected the proper descriptive code when more than one anatomical location was indicated.
Reviewed, analyzed and managed coding of diagnostic and treatment procedures contained in outpatient medical records.
Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
Resourcefully used various coding books, procedure manuals, and on-line encoders.
Interacted with providers and other medical professionals regarding billing and documentation policies, procedures and regulations.
Experience
2-5 Years
Level
Junior
Education
Information System
Jr. Claim Examiner Resume
Objective : To obtain a position within company utilizing 20 years of Health Insurance experience from processing Professional and Facility medical claims, or being a lead customer service representative.
Skills : Shorthand 10-Key, Terminology Coding, Type 60 Wpm.
Description :
Responsible for managing a high volume workload concerning worker's compensation claims.
Responded to numerous emails and phone calls daily.
Able to multitask to accomplish the tasks of contacting employers, injured workers, and providers to facilitate the worker's compensation process.
Responsible to make initial contacts and complete the first investigation of each incoming claim.
Helped to quickly facilitate the direction of a claim and make the appropriate decisions to ultimately close the claim in a timely manner.
Claimed the examiner has utilized strong organizational skills, ability to multitask and valuable customer service skills.
Processed Commercial COB as well as many other different types of claims.
Experience
2-5 Years
Level
Junior
Education
BA
Claim Examiner/Co-ordinator Resume
Summary : Claim Analyst with nine years experience processing medical and hospital claims. Accurately investigate and resolve claim issues, processing payments or denials accordingly.
Skills : Bilingual- English and Spanish, Management.
Description :
Interpreted policy provisions to determine eligibility and make claim determinations for Small Market, National, and Regional customers.
Initiated investigations through both company and external contacts to obtain medical and vocational evidence required for approval of a claim.
Established action plans for each file to bring a claim to resolution.
Evaluated claims to identify situations requiring referral to Senior Examiner.
Responded to written and/or telephone inquiries from policyholders, employers, and beneficiaries to resolve claim issues.
Actively pursued and followed up on open claims within specified timeframes.
Maintained production and quality standards.
Experience
7-10 Years
Level
Management
Education
Bachelor Of Science s
Claim Examiner/Representative Resume
Summary : Superior Health Service Professional and Administrative Assistant with a proven work ethic and ability to establish rapport with customers.
Skills : Technical Skills, MS-Excel.
Description :
Processed claims timely and accurately in full accordance of Medicare-Medicaid guidelines, as well as guidelines set forth by the Health Plan.
Alerted management promptly of any identified issues that impact quality and production.
Met or exceeded quality and production standards set forth by management.
Identified and elevate potential Coordination of Benefits.
Monitored and followed up on pending claim activity timely and accurately.
Provided phone back-up for the Customer Service department as needed.
Assisted manager with reports and special projects as needed.
Experience
7-10 Years
Level
Management
Education
Diploma
Claim Examiner II Resume
Headline : The competition for employment in today's world is astounding; however, a college degree in itself does not guarantee success in a position. Work experiences along with continuing higher education.
Skills : Communication Skills, MS-Office.
Description :
Investigated, evaluated, negotiated, and settled claims, while exercising sound judgment.
Communicated effectively with all parties involved in a claim.
Developed and analyzed insurance contract data. Investigated coverage questions and claims.
Interpreted, evaluated, and prepared settlement estimates.
Successfully negotiated settlements with policyholders and claimants or their representatives.
Created and maintained a strong return to work program by assisting the insured's and claimants to develop realistic solutions.
Able to commute from home when work allowed.
Experience
5-7 Years
Level
Executive
Education
Occupational Education
Lead Claim Examiner Resume
Headline : Looking to obtain a Medical position with a stable Company with advancement opportuni- ties. Strongly motivated and ambitious idividual, personable as well as a teamplayer and leader.
Skills : Technical Skills, Management.
Description :
Processed provider claims with a minimum of 97% procedural accuracy and 99% financial accuracy.
Maintained daily claims production standards. New Claim Entry, Keyed Claims and Copy Claims.
Maintained working knowledge of plan benefits designed.
Analyzed and authorized claim payment according to policies and provisions of the plan.
Reviewed and completed pended claims on a daily basis.
Entered and updated client/patient demographics and insurance information.
Completed miscellaneous tasks upon request/Support Service.
Experience
5-7 Years
Level
Executive
Education
Medical
Associate Claim Examiner Resume
Headline : Innovative professional with six years of progressive experience within hotel sales industry. Competent at managing responsibilities in fast-paced, high-volume atmosphere Schedule flexible.
Skills : Technical Skills, Quick Learner.
Description :
Obtained and analyzed information to make claim decisions and payments on LTD, Voluntary disability and WOP claims.
Calculated and pays benefits due, and makes timely claim payments. Communicates with the facility and billing dept.
Responded to customer service issues within the required timeframes.
Referred claims above authority to a team lead/supervisor/manager.
Demonstrated the ability to independently handle claims.
Reported overpayments, underpayments, and other irregularities.
Trained on the coordination of benefits for MI and WA professional and facility claims.
Experience
5-7 Years
Level
Executive
Education
BBA
Asst. Claim Examiner Resume
Summary : Relevant work experience is in a claim environment working with injury claims including reviewing medical reports and bills. Experience in servicing existing accounts and reporting claims.
Skills : Computer, Word, Dictation Equipment, Office Equipment.
Description :
Conducted prompt and thorough investigations. Analyzed facts to identify any third-party liability.
Evaluated facts, laws, and damages to make liability decisions.
Reviewed estimates on property damage to determine the extent of the company's liability.
Analyzed facts and monitored activities in order to identify possible fraud or abuse.
Referred potential fraud or abuse claims to the proper fraud adjuster.
Wrote correspondence with medical providers, witnesses, policyholders, and attorneys.
First trained on processing guidelines for Medicare par and nonpar providers.
Experience
10+ Years
Level
Senior
Education
Diploma
Claim examiner Resume
Headline : Detail oriented Medical Billing/ Claims Examination with experience processing claims for various State Medicaid's, Medicare and replacement HMO's and 11 years customer service experience.
Skills : Bilingual- English And Spanish, Communication Skills.
Description :
A claims examiner manages a caseload of insurance claims.
Reviewed new claims to assess their validity. Investigate ability and availability for work.
Determined which claims require further investigation.
Recommended how each claim within her caseload should be resolved.
Examiner reached out to claimants to verify and complete his claim reports.
Reviewed previously paid claims for error or overpayment.
Investigated Keeps meticulous records of each of the cases assigned.
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