Claims Examiner Resume Examples

Claims Examiner with 7 years of experience handling commercial general liability claims. Able to handle assigned claims following company guidelines and industry best practices with a minimal amount of supervision. Thorough understanding of coverage interpretation and litigation. Comfortable performing other tasks and duties within claims departments as dictated by business needs.

• Complete a highly detailed investigation on each claim in a timely manner and fully document the file with pertinent information
• Assess policy details to determine accurate coverage interpretation
• Prepare appropriate coverage letters to be submitted to and approved by claims management
• Maintain consistent contact with involved parties to keep all informed of claim progress
• Set accurate reserves on each claim within given authority level and promptly bring claims that will require reserves in excess of their authority to their supervisor’s attention
• Maintain a diary system that assures that each assigned claim will receive necessary ongoing attention
• Closely manage defense counsel and the litigation process to ensure that loss adjustment expenses are appropriate

• Reviewed investigated and adjudicated claims and encounters for medical services through contractual provisions in accordance with provider contracts and authorizations
• Processed new claim suspensions and reprocess (as needed) for discrepancies; as well as review other documentation for edits and consistency
• Absorbed and applied wide range of information about the company policies procedures and benefits
• Met individual and department standards with regards to both quality and productivity goals

• Investigate auto related claims to determine coverage and liability settling auto related property damage claims and mitigating damages through prompt handling

• ICD-9/Coding Certificate