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Claims Examiner II Resume Example

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CLAIMS EXAMINER II
Summary
To find an opportunity that will allow me to demonstrate that I am a hardworking individual, who is eager to increase my knowledge and skills, thereby becoming an asset to the company. I am an experienced professional who can solve specific problems.
Highlights
  • Microsoft Office proficiency
  • Excel spreadsheets
  • Meticulous attention to detail
  • Results-oriented


  • Insurance eligibility verifications
  • Claims appeal procedures
  • Workers' Compensation knowledge
Accomplishments
Notary Public as of February 5, 2016 with American Association of Notaries in Austin, Texas.
Experience
Texas Department of InsuranceFebruary 2009 to November 2015Claims Examiner II
El Paso, TX
  • Division of Workers' Compensation Evaluates and investigates complex and general claim matters; reviews and processes system participant requests within regulatory and/or statutory time frames and issues correspondence to claim parties regarding Division determinations.
  • Researches and reviews claims to answer questions and/or obtaining information from Division staff or system participants either in person or telephonically and document customer contacts in the Division system.
  • Serves as the Single Point of Contact for injured employees as assigned; researches and responds to injured employee's inquiries and escalated customer service matters from other system participants.
  • Identifies potential compliance issues and makes appropriate referrals to appropriate Division staff and/or external entities for investigation.
  • Answers walk-in and telephone customers' questions; provides preliminary information and general assistance in claims activities including providing brochures and forms.
  • Verifies, with injured workers' assistance, that claim information on mainframe computer screen is accurate; updates and corrects as needed; reviews and logs receipt of forms; documents all customer contacts.
Workforce Solutions November 2006 to March 2009Account Executive
El Paso, TX
  • Responsible for developing a professional liaison between employers and Upper Rio Grande Workforce.
  • Perform as a consultant to employer contacts on job creation, descriptions, and hiring.
  • Work with business executives, community organizations and various Chambers of Commerce to promote business services.
  • Participate with organizations like the Society of HR Managers-SHRM, Northeast Business Association, Central Business Alliance, and other business functions to promote the Business Services Unit (BSU).
  • Expected to be extremely hands-on in making contact efforts, including on-site and off- site meetings with employer leads, assistance in employer prospecting, attending networking events and aggressively seeking leads, staffing trade and job shows, and more to achieve goals.
  • Provide employers with labor market information, wage analysis, workers compensation, child labor laws, benefits, human resources policies, and tax credits.
  • Good understanding of the El Paso market and the ability to inform employers of the necessary contact information to meet their business needs.
  • Increase the number of job orders within their assign areas of responsibility to meet or exceed the performance measures.
  • Maintain a continual review on progress toward achieving the targeted objectives and goals.
  • Mutually develop internal individual objectives and goals with BSU Manager/Project Director.
  • Ensure performance measurements designed by Texas Workforce Commission and Upper Rio Grande Workforce Board are understood and recognized as evaluative measures.
Texas Workforce CommissionNovember 2001 to March 2006Claims Examiner
El Paso, TX
  • Performs Unemployment Insurance (UI) Program claims work in the El Paso Tele- Center of the Texas Workforce Commission by following established procedures and protocol.
  • Investigates and makes determinations on initial, additional, reopen, and claims certifications regarding payment of unemployment insurance to claimants and liability of employers for charge backs; including separation type cases like quit and fired issues.
  • Investigates and adjudicates UI claims with quality, courtesy and timeliness.
  • Organizes cases according to Tele-Center standard policies.
  • Experience in processing New Hire and non-separation class and cases in a UI Tele- Center or UI Adjudication Unit preferred.
  • Obtains all necessary information and offers rebuttal opportunities prior to issuing a quality determination.
  • Interview individuals by phone and simultaneously enter data into computer.
  • Explains the Texas Unemployment Insurance Compensation Act and other applicable laws to the claimant and employer.
  • Investigates, reviews and researches information obtained and performs functions as needed to ensure quality and timely processing of UI claims.
  • Works quickly, performs multiple tasks, pays attention to detail, enters and retrieves data from computer, and provide quality customer service.
  • Adheres to telephone schedule and strict deadlines.
  • Adheres to agency rules, policies, and procedures.
  • Handles hostile or challenging clients in a professional manner.
  • Strong word processing and typing skills.
Education
Park UniversityDecember 2014Business ManagementFt. Bliss, TexasBusiness Management
Park UniversityCurrentUndergraduate BA: Public AdministrationFt. Bliss, TexasPublic Administration
Languages
Bilingual Spanish/English
Skills
Excellent attention to detail in forms, benefits, consultant, clients, customer service, hiring, human resources, insurance, mainframe, meetings, networking, policies, processes, progress, quality, phone etiquette, typing skills, type and word processing.
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Resume Overview

Companies Worked For:

  • Texas Department of Insurance
  • Workforce Solutions
  • Texas Workforce Commission

School Attended

  • Park University

Job Titles Held:

  • Claims Examiner II
  • Account Executive
  • Claims Examiner

Degrees

  • Business Management
    Undergraduate BA : Public Administration

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