Senior Claims Representative III Resume Example AFA Claims / Confie / Bluefire

SENIOR CLAIMS REPRESENTATIVE III

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

AFA Claims / Confie / BluefireSeptember 2015 to May 2020Senior Claims Representative III
Irving, TX

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.

National General Insurance CompanySeptember 2013 to September 2015Casualty Representative II
Ontario, CA

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.

AFA Claims / NationsMarch 2010 to September 2013Bodily Injury Claims Specialist
Anaheim, CA

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.

Farmers Insurance GroupJanuary 2008 to March 2010Special Claims Representative
Orange, CA

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

University of PhoenixJanuary 2008Bachelor of Science: Business ManagementCosta Mesa, CA

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

Resume Overview

Companies Worked For:

AFA Claims / Confie / Bluefire
National General Insurance Company
AFA Claims / Nations
Farmers Insurance Group

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 : Business Management

Senior Claims Representative III Resume Example

Resume Score: 80%

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