Claim Examiner handling complex and catastrophic claims, lost time and medical only claims. Attends Mediations, EDI filing, handles all facets of the claim from start to finish. Handling National and Local accounts. Provides support and information to local employers regarding return to work and right of choice decision. Utilizing three claim system and maintains an updated diary on all accounts. Litigation and medical case management over site
- Claim Examiner at S&C Claims Services Inc
- Claim Examiner at York Risk Services
- Compensation Claim Examiner at Mountain States Insurance
- Worker's Compensation Examiner at Workers
3 years, 2 months at this Job
- Bachelor's. Degree - Sociology of Medicine
Serves as a Claim Examiner II for Disability Determination Services. Assisted with adjudicating claims for Social Security Administration
• Analyzed moderate to complex worker’s compensation to determine benefits due
• Applied the SSA Sequential Evaluation Examinations process to determine whether a claimant is disabled
• Prepared a detail analysis of cumulative effect of all medically determined physical and mental impairments
• Assisted and delivered on client specific metrics and requirements on an ongoing monthly while maintaining high file quality audit scores
• Developed complete claimant vocational profile for adults
• Created forms, letters and supporting materials required to document disability decisions
• Identified and reports for investigation cases involving potential fraud
• Established standard for customer focused communication and coordination within areas of responsibility and with all internal and external associates and customers
- Claim Examiner II at Disability Determination Services
- Texas Work Advisor II at Texas Health and Human Service Commission
- Senior Human Resources Supervisor /S-1 NCOIC at Warrior Transition Battalion
- Human Resources Specialist at 720th Military Police Battalion
8 months at this Job
- Bachelor's - Business Administration emphasis technology
process medical claims take calls research and analyze claim before issue payment
- claim examiner at ct pipes trades health fund office
18 years, 1 month at this Job
- Associate - Business
Responsibilities include handling of medical only and lost time claim processing and payment of medical invoices. Claim processing requires interviews, wage calculation, obtaining and review medical records. Prepare for and participate in telephonic claim reviews. Handle phone inquiries and answer questions regarding claims and invoicing. Support staff working remotely processing technical and administrative requests. Familiar with medical terminology. Assist and train others with computer programs and works with a variety of office equipment.
- Claim Examiner at
- Claim Specialist at
- Medical Only Adjuster at Broadspire Services
2 years, 2 months at this Job
Analyzes complex claims by investigating and gathering information to determine the exposure on the claim. Manages claims through developed action plans to an appropriate and timely resolution. Negotiates settlement of claims within designated authority. Communicates claim activity and processing with the claimant and the client; maintains professional client relationships. Manages the litigation process; ensures timely and cost effective claims resolution. Often given projects to reduce claim errors and train staff on improved processes.
- Claim Examiner at Sedgwick CMS
- Claim Examiner (Healthcare) at Keenan & Associates
- Social Committee Member at Sedgwick CMS
- Claim Examiner at Sedgwick CMS
1 year, 8 months at this Job
- B.A. - Communication Studies
• Provide high quality, timely service to policy holders, beneficiaries, attorneys, and business directors to resolve issues by offering recommendations and solutions.
• Actively pursue and follow up on open claims within specified time frames.
• Work with employer group administrative staff to clarify plan provisions and resolve claim discrepancies.
• Manage and organize objectives to meet multiple deadlines and competing priorities to ensure departmental turnaround and customer satisfaction are met.
• Adjudicate and process claim payments up to $250,000.
- Claim Examiner at Metropolitan Life Insurance
- Claim Reviewer at
- Solutions Specialist at Verizon Wireless Communications
- Optical Assistant at Empire Visionworks in North
7 months at this Job
- BS in Communication - Communication
Duties and Responsibilities:
• Complete required investigations escalated claims involving litigation and serious injury.
• Reduce loss ratios through fair and prompt adjudication of complex, litigated commercial general liability claims
• Obtain and analyze relevant evidence and information to execute the thorough analysis of settlement demand packages.
• Interview claimants, medical specialists, attorney's and client personnel to determine pertinent claim information
• Mentor and coach sever Level II and Claim Assistant claim staff members.
• Contact injured parties and legal representatives to negotiate final settlements for injury claims.
• Drafted reserve and settlement evaluations driven by claim details, jurisdiction and damages.
• Draft settlement releases and all other claim correspondence specific to the needs of the claim
• Prepare and present settlement evaluation and liability analysis reports to the client and claim management persons.
• Negotiate and achieve settlement within my desk authority
• Coordinate pre-suit settlement mediations to aggressively pursue settlement in lieu of costly litigation
• Ensure data integrity of all claim files, especially litigated claims
• Manage to adjudication, defense and resolution of claim - even when they are litigated.
- Claim Examiner III/ Litigation Consultant at Sedgwick Claim Management Services
- Senior Claim Adjuster at County of Henrico, Division of Risk Management
- Domestic Manager at
- Benefit Analyst II (Initial Eligibility Adjudication) at Genworth Financial
1 year, 8 months at this Job
- Bachelor of Science in Interdisciplinary Studies - BS.INT
- B.B.A. - Finance
• Contact all parties involved in assigned claims within 8 business hours of receipt
• Determine coverage under insured's policy
• Establish and complete full liability investigation
• investigate all physical damages and bodily injury damages
• Set proper reserves based on actual damages and application of liability
• Work closely with defense counsel to establish and proceed with necessary discovery on matters in litigation
• Evaluate claim and negotiate settlement
• Acted as mentor in Company program to develop property adjusters in bodily injury claim handling
- Claim Examiner at National Interstate Insurance Company
- Risk Management Department - Claim Adjuster at ELECTROLUX NORTH AMERICA, INC
- Full time temporary Claim Consultant at INSURANCE OVERLAOD STAFFING SYSTEMS
- Property Supervisor, Casualty Supervisor, Casualty Unit Manager, Multi-Line Unit Manager, Assistant Regional Field Claim Office Manager at PRUDENTIAL PROPERTY & CASUTLTY INSURANCE COMPANY/LIBERTY MUTUAL INSURANCE COMPANY
3 years at this Job
Examining and investigating all types of Disability Insurance claims; scheduling independent medical examinations when appropriate, and analyzing all employment data in order to determine claimant's eligibility and claim duration; making eligibility determinations and informing claimants; filing workers' compensation liens when injury is work related; documenting all actions and decisions; following up on claimant's status through duration of claim; identifying and reporting any suspected fraudulent claims or activities; and responding to inquiries from claimants and the public.
- Claim examiner at State of California
- Sunday School Teacher (Volunteer) at Christian alliance missionary church of Stockton
- Key data operator at State of California edd
- Data Entry Clerk at Medtox Laboratories
7 months at this Job
- Bachelor's - Psychology
• Responsible for answering provider questions in regards to claims payment, Maintain departmental productivity standards.
• Analyze, process, research, adjustment of all provider reconsideration requests and correspondence in a timely and accurate manner.
• Assist with special projects as needed.
• Other duties as assigned by management.
- Claim Examiner at Cal Optima
- Provider Dispute Resolution Examiner at Care 1st Health Plan
- Claims Processor at Med Point Management
- Authorization Technician at Allied Physicians
1 month at this Job