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Project Claim Specialist Resume Example

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PROJECT CLAIM SPECIALIST
Experience
July 1993 to January 2018STATE FARM INSURANCE － Chicago, IL
Project Claim Specialist
March 2007 to January 2018SIU Major Case
  • Managed complex medical insurance fraud investigations with a focus on multi-claim organized activity.
  • Analyzed billing, trending, and exposure data and reviewed claim documentation to identify potential insurance fraud.
  • Developed resolution strategies to address potential fraud exposure, leveraged investigative findings, and implemented guidelines to achieve timely claim resolution across multiple project investigations and thousands of associated claim files.
  • Resisted non-meritorious billings in excess of $12 million over past three years and secured an additional $2 million in judgments, negotiated settlements, and collected restitutions.
  • Created and initiated new methods to identify questionable claims within department, resulting in 125% increase in number of referrals to SIU (Special Investigative Unit).
  • Decreased indemnity costs by millions of dollars by reducing or eliminating submission of questionable billings of non-meritorious claims from providers with high-dollar exposures by applying aggressive investigation techniques.
  • Led multiple project investigations and teams of claim handlers through implementation of claim handling guidelines tailored to each investigation to ensure consistency and appropriate claim resolution.
  • Facilitated collaboration calls with teams of claims handlers, analysts, management, and counsel, discussing and sharing investigative findings and ensure recommended strategies for handling questionable claims were appropriate and successful.
  • Selected by leadership to participate in multiple working groups tasked with developing new resources to improve processes and workflows, create efficiencies, track productivity, and collect, manage, and organize investigative data for company-wide use.
  • Created an Excel Workbook to be used by claim specialists to collect and organize claim data related to individual project investigations.
  • The workbook created efficiencies by reducing the time spent collecting claim data needed to prepare mandatory quarterly reports.
  • Recommended changes to an existing database used to track productivity to more accurately reflect the time required to complete daily activities.
  • The new data collected in this database provided an accurate basis for establishing realistic metrics.
  • Recommended changes to Standard Claim Practices which were considered and ultimately implemented.
  • The changes eliminated duplicative work and streamlined the process for closing project investigations resulting in a more efficient workflow by eliminating unnecessary steps.
  • Partnered with project counsel to manage complex affirmative litigation, positioning State Farm to obtain favorable outcomes including judgments, negotiated monetary settlements, and walkaways from pending claims.
  • Mentored and contributed to development of peers, resulting in high-performing, collaborative team environment.
SIU Claim Specialist
February 1997 to March 2007Northwest Indiana
  • Initiated complex investigations on questionable property and injury claims, using National Insurance Crime Bureau (NICB) indicators to determine State Farm's payment obligations under policy contract.
  • Managed caseload of approximately 70 claims per month.
  • Analyzed, interpreted, and applied policy contract to first- and third-party claims, conducting comprehensive investigations that resulted in efficient and appropriate claim resolution recommendations.
  • Utilized internal and external resources to conduct investigative public record searches, employ forensic and medical experts, interview claim participants and witnesses, and canvas loss locations to effectively analyze, investigate, and move appropriate claim resolution recommendations.
  • Delivered deposition and trial testimony in civil proceedings on behalf of State Farm securing favorable litigation outcomes.
  • Served as a liaison to the public, governmental entities, and law enforcement agencies on insurance fraud issues.
Claims Specialist
July 1993 to February 1997Indiana
  • Investigated, evaluated, and negotiated property, total loss, liability, and medical payments claims in a fast-paced environment, adhering to statutory and regulatory fair claims practices.
  • Managed a monthly inventory averaging between 250-300 claim files.
  • Led the unit in the number of questionable claims identified and referred to SIU through detailed and thorough claim investigations and the recognition of questionable loss indicators.
Education
Bachelor of Science : MathematicsPURDUE UNIVERSITY － Lafayette, INMathematics THE INSTITUTES Chartered Property Casualty Underwriter (CPCU)
Chartered Life Underwriter (CLU) AMERICAN EDUCATIONAL INSTITUTE Fraud Claims Law Specialist (FCLS)THE AMERICAN COLLEGE
Summary
High-performing insurance professional with more than 20 years of Special Investigative Unit experience at a Fortune 50 insurer with a current focus on complex medical provider investigations. Exceptionally skilled in detecting potential fraudulent activity through billing/data analysis and pattern identification. Lead claim handling teams in resisting millions of dollars' in non-meritorious claim payments by leveraging critical thinking and developing claim resolution strategies which limit future exposure. Provide guidance and direction to the claim handling teams in implementing claim handling guidelines to address the potential fraudulent activity. Possess strong interpersonal and communication skills to liaise with various internal stakeholders and counsel.
Certifications
Core Competencies Insurance Fraud | Investigation Practices and Techniques | Process Improvements Data and Trend Analysis | Time Management | Adaptability |Peer Mentoring and Leadership| Collaboration
Affiliations
International Association of Special Investigative Units (IASIU) CPCU Society Phi Beta Kappa
Highlights
Microsoft Office: Word, Excel (advanced), PowerPoint, Outlook, Access, Visio Statistical Analysis System (SAS) | Screened Intake for Potential Fraud Tool (SIPFT) | Think Analyze Connect (TAC)
Skills
billing, billings, canvas, closing, database, documentation, fast, focus, Insurance, inventory, law enforcement, Leadership, Law, litigation, Mentoring, Access, Excel, Microsoft Office, Outlook, PowerPoint, Word, positioning, improve processes, SAS, settlements, Statistical Analysis, Time Management, Trend, Underwriter, Visio, workflow
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Resume Overview

Companies Worked For:

  • STATE FARM INSURANCE
  • SIU Major Case
  • Northwest Indiana

School Attended

  • PURDUE UNIVERSITY
  • THE AMERICAN COLLEGE

Job Titles Held:

  • Project Claim Specialist
  • SIU Claim Specialist
  • Claims Specialist

Degrees

  • Bachelor of Science : Mathematics
    Chartered Life Underwriter (CLU) AMERICAN EDUCATIONAL INSTITUTE Fraud Claims Law Specialist (FCLS)

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