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Senior Claims Representative Iii resume example with 12+ years of experience

Jessica Claire
Montgomery Street, San Francisco, CA 94105 609 Johnson Ave., 49204, Tulsa, OK
Home: (555) 432-1000 - Cell: - resumesample@example.com - -
Summary

Enthusiastic individual with superior skills in working in both team-based and independent capacities. Bringing strong work ethic and excellent organizational skills to any setting. Seeking position where I can utilize my extensive customer service and analytical skills in multiple dimensions of the insurance claims industry. Excited to begin new challenge with successful team.

Skills
  • Investigation management
  • Fraud identification
  • Claims file management processes
  • Complex claims experience
  • High-exposure claims background
  • Claims processing documentation
  • Complex problem-solving mastery
  • Complex negotiations
  • Complex coverage issues
Experience
09/2015 to 05/2020
Senior Claims Representative III Nationwide Gallipolis, OH,
  • Investigated and resolved liability and complex liability / Resolved coverage and complex coverage investigations for losses.
  • Reviewed and evaluated complex injury claims including limb loss / amputations, keloid and fatalities
  • Reviewed and evaluated medical bills / CPT Codes / ICD9 & 10 Codes
  • Compliance with HIPPA laws (where applicable)
  • Medicare Regulations and government entities were protected
  • Maintained heavy caseload and followed Fair Claims Act as set forth by the appropriate state department.
  • Developed settlement ranges / PEV (Pure Exposure Value) and accurate reserves
  • Handled both 1st and 3rd party claims represented and non-represented
  • Attended small claims / Attended and successfully negotiated mediation as needed
  • Multiple States ( WA, CA, TX, AZ)
  • Commercial General Liability (including but not limited to municipalities)
  • Earned reputation for good attendance and hard work.
  • Recognized by management for providing exceptional customer service.
09/2013 to 09/2015
Casualty Representative II National General Insurance Company City, STATE,
  • Reviewed and resolved liability and complex liability cases / reviewed and resolved coverage investigations; Reviewed and evaluated moderate to complex injury claims including fatalities
  • Reviewed medical bills / CPT Codes / ICD9 & 10 Codes
  • Compliance with HIPPA laws (where applicable)
  • Medicare Regulations protected
  • Developed settlement ranges / PEV (Pure Exposure Value) and accurate reserves
  • Handled 1st and 3rd party Bodily Injury claims both pro per and legal represented
  • Attended small claims as needed
  • States handled OR ; NV ; CA
  • Attended anti-fraud training courses, conferences, client SIU training and industry seminars annually
  • Managed a case load of 175-210 exposures at any one given time
  • Conducted interviews, gathered detailed information and completed field investigations.
  • Contacted injured parties and legal representatives to negotiate final settlements for claims.
03/2010 to 09/2013
Bodily Injury Claims Specialist AFA Claims / Nations City, STATE,
  • Investigated and resolved liability and complex liability / Resolved coverage and complex coverage investigations for losses.
  • Reviewed and evaluated complex injury claims including limb loss / amputations, keloid and fatalities
  • Reviewed and evaluated medical bills / CPT Codes / ICD9 & 10 Codes
  • Compliance with HIPPA laws (where applicable)
  • Medicare Regulations and government entities were protected
  • Maintained heavy caseload and followed Fair Claims Act as set forth by the appropriate state department.
  • Developed settlement ranges / PEV (Pure Exposure Value) and accurate reserves
  • Handled both 1st and 3rd party claims represented and non-represented
  • Attended small claims / Added and successfully negotiated mediation as needed
  • Multiple States ( WA, CA, TX, AZ)
  • Commercial General Liability (including but not limited to slip and fall claims)
  • Earned reputation for good attendance and hard work.
  • Recognized by management for providing exceptional customer service.
  • Verified liability extent with reviews of police reports, medical treatment histories and other records.
  • Checked into questionable claims, interviewing agents and claimants to resolve errors and omissions.
01/2008 to 03/2010
Special Claims Representative Farmers Insurance Group City, STATE,
  • Reviewed and resolved liability and complex liab / reviewed and resolved coverage for losses
  • Reviewed and evaluated moderate to complex injury claims including loss of limbs and fatalities
  • Successfully handled the following lines: Personal Auto / Personal Home / Commercial Auto / Commercial Auto Fleets; Occurrence basis claims; Premise Liability; Product Liability for self-insurance, public entities and municipalities – Commercial General Liability / Business Owners Policy
  • Reviewed medical bills / CPT Codes / ICD9 & 10 Codes
  • Reviewed regulations and health codes (USDA; FDA; Municipality Heath Departments)
  • Review updated building codes
  • Compliance with HIPPA laws (where applicable); Medicare Regulations protected
  • Maintained heavy caseload and followed Fair Claims Act as set forth by the appropriate state department
  • Developed settlement ranges / PEV (Pure Exposure Value) and accurate reserves
  • Identify resources for Risk Control
  • Attended depositions, mediations, arbitrations and small claims as needed
  • Explained loss coverage, assisted policyholders with itemizing damages and coordinated alternative living arrangements.
  • Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
  • Earned reputation for good attendance and hard work.
Education and Training
Expected in 01/2008
Bachelor of Science: Business Management
University of Phoenix - Costa Mesa, CA,
GPA:
Additional Licenses
  • Independent Insurance Adjuster / Qualified Manager Dept of Insurance California 2C57578 Issued 6/18/2014 expiration 05/31/2022
  • Adjuster Property and Casualty Dept of Insurance Texas 1774666 Issued 11/6/2015 expiration 12/31/2021
  • Independent Adjuster License Dept of Insurance Washington 912371 Issued 2/16/2016 expiration 12/31/2021
  • Adjuster Dept of Insurance Arizona 2771676 Issued 4/1/2019 expiration 12/31/2022

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Resume Overview

School Attended

  • University of Phoenix

Job Titles Held:

  • Senior Claims Representative III
  • Casualty Representative II
  • Bodily Injury Claims Specialist
  • Special Claims Representative

Degrees

  • Bachelor of Science

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