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claims adjuster resume example with 14+ years of experience

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Jessica Claire
, , 100 Montgomery St. 10th Floor (555) 432-1000, resumesample@example.com
Summary

Talented Claims Adjuster emphasizing effective time management, cost control and mediation. Self-motivated and customer-focused. Strategic-minded Claims Adjuster offering more almost 15 years of experience working for insurance companies. Offering exceptional skills in customer service, interviewing policyholders and coordinating services. Seek to take on similar role with leading organization. Energetic and enthusiastic insurance professional motivated to succeed in fast-paced and deadline-driven professional environment. Comprehensive knowledge of claims adjustments with special knowledge of auto appraisals and CCC pathways estimations.

Skills
  • Workers' compensation claims
  • Medicaid knowledge
  • Database management
  • Skilled in Microsoft Office Suite, SIR, Juris, Microsoft Teams.
  • Patient rapport
  • Account management expertise
  • Regulatory compliance understanding
  • Documentation skills
  • Outstanding clerical abilities
  • Background in insurance
  • Reporting abilities
  • Insurance terminology
  • Secure data practices
  • Medical terminology
  • Exceptional recordkeeping abilities
  • Critical thinking
  • Friendly, positive attitude
  • Decision-making
Experience
06/2012 to Current Claims Adjuster Kemper Corp. | Houston, MN,
  • Adhered to company and insurance client's guidelines in claims processes, estimate writing and claim closures.
  • Recommended settlement offers and negotiated payment arrangements.
  • Conducted interviews, gathered detailed information and completed field investigations.
  • Obtained necessary information to complete proper evaluation of injury claims.
  • Reviewed data to verify validity of claims and determine case management actions.
  • Completed required investigations on referred files within established timeframes.
  • Analyzed first reports of loss and underlying file material to determine if claim was suspect.
  • Contacted injured parties and legal representatives to negotiate final settlements for claims.
  • Investigated potentially fraudulent claims with focus on thoroughness, quality and cost control.
  • Reduced loss ratios through fair and prompt processing of claims.
  • Interviewed claimants, medical specialists and employers to determine pertinent claim information.
  • Mentored new members of claims staff in proper procedures.
  • Obtained relevant evidence and information regarding suspicious claims.
  • Attended yearly anti-fraud training courses, conferences, client SIU training and industry seminars.
08/2011 to Current Claims Examiner Aegon | Denver, CO,
  • Paid and processed claims within designated authority level.
  • Adhered to company and insurance client's guidelines in claims processes, estimate writing and claim closures.
  • Reviewed, evaluated and adjusted claims to promote fair and prompt settlement.
  • Researched and followed up on denied insurance claims.
  • Evaluated acceptability of claims from third-parties and gathered comprehensive information.
  • Analyzed and audited open claims to calculate additional payments owed.
  • Maintained thorough understanding of fraudulent and illegal practices.
  • Verified and analyzed claims settlement data to ensure validity.
  • Attended yearly anti-fraud training courses, conferences, client SIU training and industry seminars.
  • Entered claim transactions, payments, reserves, and other documentation.
  • Reviewed claims to ensure accuracy, resulting in multiple claim reductions.
  • Double-checked and reviewed documentation for denied and accepted insurance claims.
  • Investigated questionable claims to determine payment authorization.
  • Obtained necessary information to complete proper evaluation of injury claims.
  • Completed required investigations on referred files within established timeframes.
  • Reviewed and resolved open claims and change orders to determine entitlement for additional payment.
  • Gathered information from various third parties to determine claim acceptability.
  • Analyzed first reports of loss and underlying file material to determine if claim was suspect.
  • Evaluated evidence with ultimate goal of creating positive outcomes for client's claims.
08/2009 to Current Medical Only Claims Adjuster Amtrust Financial Services, Inc. | Sacramento, CA,
  • Stayed current on HIPAA regulations, benefits claims processing, medical terminology, and other procedures.
  • Accurately processed large volume of medical claims every shift.
  • Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
  • Reviewed claims for accuracy before submitting for billing.
  • Inputted data into the system, maintaining accuracy of provider coding information and reported services.
  • Based payment or denials of medical claims upon well-established criteria for claims processing.
  • Sent clinical request and missing information letters to obtain incomplete information.
  • Reviewed administrative guidelines whenever questions arose during processing of claims.
  • Documented file notes clearly and concisely in Juris and SIR.
  • Administered standard contract benefits to process pending claims for dental benefits.
  • Determined insurance coverage levels and restrictions by thoroughly examining claims forms and associated records.
  • Conducted interviews, gathered detailed information and completed field investigations.
  • Conducted detailed bill reviews to implement sound litigation management and expense control.
  • Delivered exceptional customer service to clients by communicating information and actively listening to concerns.
  • Identified suspicious losses, immediately contacting supervisors to have claim moved up to lost time adjuster to conduct further investigations.
  • Uploaded documentation and reports to corporate database system using SIR to facilitate smooth claims processing.
  • Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
  • Reviewed police reports, medical treatment records, medical bills and physical property damage to determine extent of liability.
  • Analyzed first reports of loss and underlying file material to determine if claim was suspect.
  • Reduced loss ratios through fair and prompt processing of claims.
  • Verified liability extent with reviews of police reports, medical treatment histories and other records.
  • Attendant yearly annual anti-fraud training courses, conferences, client SIU training and industry seminars.
11/2007 to Current Claims Assistant Matrix Absence Management | South Portland, ME,
  • Verified policy holder data, including age, contact number and physical address.
  • Complied with confidentiality regulations in handling customer information.
  • Checked documentation for appropriate coding, catching errors and making revisions.
  • Instructed clients on amounts covered under benefits plans in easy-to-understand terminology.
  • Updated patient and insurance data and input changes into company's computer system.
  • Processed claims for payment or forwarded to appropriate personnel for further investigation
  • Composed business correspondences for supervisors, managers and other professionals.
  • Collaborated with fellow team members to manage large volume of claims.
  • Retained strong medical terminology understanding in effort to better comprehend procedures.
  • Handled billing related activities focused on medical specialties.
  • Collaborated closely with other team members to resolve large volume of claims on daily basis.
Education and Training
Expected in 06/2006 to to Associate of Applied Science | Paralegal University of Cincinnati Clermont College, Batavia, OH GPA:
Certifications

I hold the certifications of FCLS, FCLA, WCCLA, PCLA, & SCLA.

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Resume Overview

School Attended

  • University of Cincinnati Clermont College

Job Titles Held:

  • Claims Adjuster
  • Claims Examiner
  • Medical Only Claims Adjuster
  • Claims Assistant

Degrees

  • Associate of Applied Science

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