Claims Adjuster Resume Example Horace Mann Insurance

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 Adjuster 08/2016 to Current Horace Mann Insurance Irving, 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 Rep 03/2016 to 07/2016 Am Trust Financial Services Bedford, 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 Rep 12/2015 to 03/2016 Corner 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 12/2015 Dialog 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 03/2015 Citigroup Fort 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 06/2002 Citigroup Fort Worth, TX Take 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

Diploma 1995

O. D Wyatt High School Fort 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

Resume Overview

Create a job alert for [job role title] at [location].

About About

Help & Support Help & Support

Languages Languages

Customer Service Customer Service

Claims Adjuster Resume Example

Resume Score: 90%