Medical Claims Examiner Resume Examples

A certified Medical Claims Examiner with experience in both the private sector and civil service positions within Worker’s Compensation.Able to thoroughly investigate and evaluate insurance claims confer with legal counsel when necessary and negotiate settlements.

• Strong analytical skills
• Clear written and verbal communication
• Ability to deal with claimants who are upset
• Strong math skills
• Knowledge of medical terminology and medical billing codes
• Attention to detail and thorough note taking

• Contacted claimant for pertinent information including description of injury.
• Maintained thorough written records related to claims.
• Obtained physician statements and relevant medical records often limiting the company’s liability.
• Referred questionable claims to outside field investigators.
• Responded to inquiries and complaints from attorneys claimants agents and employers.

• Determined if the policy of the insured covered the loss claimed.
• Investigated claims to ensure they were not fraudulent.
• Reviewed complex claims as an extra set of eyes to assist the claims adjuster and checked on the case regularly to insure proper guidelines were followed.
• Negotiated settlements to avoid going to court and authorized payments.

• Carefully reviewed evaluated and investigated insurance claims.
• Obtained additional information from claimants’ doctors on questionable claims.
• Detailed all conversations and filed periodic reports for review by claims managers.