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Claims Adjuster Resume Example

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CLAIMS ADJUSTER
Summary
Over 10 years of experience as a Sr. Claims Examiner in the Insurance industry. A self-motivated, organized and analytical professional providing thorough and skillful support to department managers.
Skills
  • Strong analytical skills Team player
  • detail-oriented Critical thinker
  • strong communication Claims file management processes
  • interpersonal skills Sales background
  • Benefits, billing, healthcare, call center, CMS, credit, data entry, ICD-9, Life and Health Insurance, problem solving
  • skills, Processing customer requests, organizational skills, analytical skills, strong communication, Research, sales,
  • shipping, troubleshooting and inter-personal skills.
Accomplishments
  • Promoted to Sr. Claims Examiner after 1 year which normally takes 18 months to 2 years with Citigroup
  • Received recognition awards during employee recognition month in 2014 and 2015 for going above and beyond with Citigroup
  • Received a 9.67 out of 10 in customer service in the first month with Horace Mann
  • Received a perfect score of 10 on a couple of customer service survey's with Horace Mann within the first 6 months
Experience
Claims Adjuster08/2016 to CurrentHorace Mann InsuranceIrving, Texas
  • Interviewed insured's and claimants, and passengers to determine pertinent claim information via phone
  • Investigated any potentially fraudulent claims with a focus on thoroughness, quality and cost control.
  • Obtained relevant evidence and information regarding suspicious claims.
  • Attended quarterly and/or annually anti-fraud training, SIU training, and claims certification training
  • Analyzed first reports of loss and underlying file material to determine if a claim was a covered loss
  • Processed payments to insureds and body shops within 24 hours of approval of an estimate and/or supplement
  • Managed rental reservations while insured in a rental during the repair process
  • Verify coverage, investigate liability and/or scope of damage
  • Proficient in the ability to understand and follow regulations for State jurisdictions
  • Operated in a fast paced customer focused environment, while effectively utilizing telephony and claims operating system
  • Investigate liability for potential subrogation
  • clearly explained the insured's coverage and what applies as it relates to the accident
  • Discussed liability
  • Coded claims for questionable risk for underwriting 
Customer Service Rep03/2016 to 07/2016Am Trust Financial ServicesBedford, Texas
  • Provided accurate and appropriate information in response to customer inquiries
  • Addressed customer service inquiries in a timely and accurate fashion
  • Maintained up-to-date records at all times
  • Developed effective relationships with all call center departments through clear communication
  • Built customer loyalty by placing follow-up calls for customers who reported product issues.
  •  Enforced Service Center policies, procedures and quality assurance measures.
  • Achieved customer satisfaction rating of 88% within 30 days exceeding the target
  • Properly directed inbound calls in phone queues to improve call flow
  • Made reasonable procedure exceptions to accommodate unusual customer requests
  • Assist Warranty customers through incoming calls from customers, vendors, merchants and service companies and resolve issues regarding specific products, warranty terms and conditions, service calls and general questions
  • Demonstrated a continual working knowledge of our client's products, services and promotions regarding the Terms and Conditions of a protection plan
  • Document all customer information, communications and sales
  • Utilize troubleshooting and problem solving skills to successfully supply accurate information to callers and resolve their issues Research, respond and resolve customer issues in a timely fashion.
Customer Service Rep12/2015 to 03/2016Corner Stone Staffing Fort Worth, Texas
  • Assisted Oncology patients Obtained information by contacting appropriate personnel or patients about medication(s) Followed-up with patients or health care providers to resolve discrepancies Maintained complete confidentiality in accordance with legal requirements Took incoming calls from patients and/or health care providers who called to schedule shipping on medication(s).
  • Updated and or made changes to patient's record. 
Licensed Health Agent 09/2015 to 12/2015Dialog Direct Fort Worth, Texas
  • Recommended and helped customers select healthcare plans based on their needs Confirmed that appropriate changes were made to resolve customers' problems Took incoming calls from interested parties to discuss our applicable insurance plans educating callers on PPO'S, HMO'S, supplemental insurance (Medigap vs Medicare advantage plans).
  • Educating callers on the details of an insurance plan, out of pocket cost; coinsurance and deductibles, doctor visits, emergency care; skilled nursing facilities; specialists, hospital visit; nursing home care, etc.
  • Qualifying callers based on specific criteria for a Telephonic Enrollment Determine the eligibility of each prospect using CMS (Center for Medicaid and Medicare Services) guidelines as applicable.
  • Created leads for the field sales team Enroll or complete plan changes for members into provider plans.
Sr. Claims Examiner 06/2002 to 03/2015CitigroupFort Worth, Texas
  • Interviewed claimants, medical specialists and employers over the phone to determine pertinent claim information Managed queues to ensure timely processing of claims Obtained relevant evidence and information regarding suspicious claims Attended anti-fraud training classes and SIU training and quarterly or yearly training needed Report any potentially fraudulent claims with a focus on thoroughness quality and cost control Mentored new members of the claim staff Evaluate claims against eligibility requirements; Research any information to support claim processing Follow up on accounts; data entry; perform benefit calculations correspond with internal/external customers both orally and written relative to policy coverage and claim status research; educating customers on their benefits; opening and starting a claims investigation on behalf of the customer and research any billing issues Processing and paying customers claims as it relates to their coverage like short term or long term disability, Life event(s), Family Medical Leave, Unemployment, National disaster, or Death coverage.
  • Reading ICD-9 codes for disability claims. 
Customer Service Rep 03/2001 to 06/2002CitigroupFort Worth, TXTake inbound calls for credit protector and credit shield Research customer concerns and complaints Research and/or solve extensive billing issues Processed credits and/or adjustments; cancellations of coverage per customer request Internal/external correspondence with bank regarding coverage/policy
Education and Training
Diploma1995
O. DWyatt High SchoolFort Worth, Texas
Interests
Volunteer work for Meals on Wheels and Tarrant County Back to School Round-up events and church activities/functions.
Skills
analytical skills, strong organization and time management skills, Benefits, billing, call center, CMS, inter-personal skills, interpersonal skills, cost control, credit, client, customer satisfaction, customer service, data entry, detail-oriented, emergency care, fashion, file management, focus, ICD-9, Insurance, legal, nursing, nursing home, Oncology, organizational skills, personnel, policies, problem solving skills,  processes, Processing customer requests,  quality assurance, Reading, Research, Sales, shipping, Team player, phone, troubleshooting,
Additional Information
  • Volunteer work for Meals on Wheels and Tarrant County Back to School Round-up events and church activities/functions.
  • Texas Department of Insurance General Lines Agent License Life, Accident, Health and HMO
  • Texas Department of Insurance Property & Casualty License
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Resume Overview

Companies Worked For:

  • Horace Mann Insurance
  • Am Trust Financial Services
  • Corner Stone Staffing
  • Dialog Direct
  • Citigroup

School Attended

  • Wyatt High School

Job Titles Held:

  • Claims Adjuster
  • Customer Service Rep
  • Customer Service Rep
  • Licensed Health Agent
  • Sr. Claims Examiner

Degrees

  • Diploma 1995
    O. D

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