Insurance Claims Examiner Resume Sample


Insurance Claims Examiner Resume Sample

Complete Name
Complete Address
Phone # / Cell Phone #
E-mail Address

Summary of Qualifications

Astute, tenacious, and accomplished professional, with solid academic foundation and proven track record of success in processing, interviewing, and investigating disability claims for the state of Tennessee. Equipped with comprehensive years of experience in medical and military operations as well as school administration. Expert in planning and executing investigations on insurance claims related to bodily injury, liability, medical, and employee compensation. Adept at gathering claimants and witnesses information/background, with the ability to review case circumstances through research, interview, surveillance, and in-person inspections of sites. Well-versed in establishing solid relationships with professionals and individuals while maintaining high ethical and quality standards, professional demeanor, and a cooperative attitude. Possess outstanding problem-solving, leadership, intellectual curiosity, and social consciousness.

 Areas of Expertise

  • Claims Administration and Functions
  • Medical Evaluation and Procedures
  • Regulatory Compliance and Standards
  • Project Management
  • Billing and Collection
  • Reports and Record Analysis
  • Customer Service and Relations
  • Training, Supervision, and Team Building

Education

Master of Business Administration, Emphasis in Corporate Training, Ongoing
XYZ University | Colorado Springs, CO

Bachelor of Business Administration, 2002
Bachelor of Music (Instrumental), 2002
WXY College | Columbia, SC

Associate of Science in Allied Health Science, 1998
Community College of the Air Force | Maxwell AFB, AL

Professional Experience

INSURANCE CLAIMS EXAMINATION / INVESTIGATION EXPERIENCE

Disability Claims Adjudicator
State of Tennessee, Department of Human Services | Nashville, TN | 2007–2011

Ensured overall compliance with the Health Insurance Portability and Accountability Act (HIPAA) regulations in settling claims for benefits offered under government social insurance program. Coordinated the collection of information, correction of errors, and omissions on claim forms to investigate questionable data through frequent collaboration with claimants and/or agents. Performed detailed payment verification of claims and inform claimant regarding denied claim and appeal rights. Meticulously administered the re-evaluation of evidence and generation of additional information in connection with claims under appeal or in cases requiring investigation of claimant’s continuing eligibility for benefits.

  • Strategically identified claimants’ eligibility for disability through analysis and evaluation of medical records and other related documents.
  • Delivered excellent service and ensured total satisfaction by preparing forms, addressing concerns concerning filing requirements and benefits provided to claimants.
  • Spearheaded the timely preparation and creation of written reports findings.

PROJECT MANAGEMENT / ADMINISTRATION / QUALITY ASSURANCE EXPERIENCE

Maintenance Worker/Inspector
Company Uvw | Fort Campbell, KY | 2004–2007

Exemplified versatility and multitasking skills in performing diverse tasks, such as inspecting, servicing, troubleshooting, and repairing electric system, air system, hydraulic systems, and engines on military ground vehicles, including Hemmets, High Utility Mobile Mechanized Vehicles (HMMWV), and Ton and Half–light medium tactical vehicles (LMTVs) on time. Closely supervised and monitored the entire operations to secure safe working environment.

Crew Chief/Equipment Manager/Hazardous Waste Manager/Dispatch and Support
United States Air Force, Active Duty | Fairchild AFB, WA | 1991-1995

Directed and oversaw the entire operations of aircraft maintenance and cleaning, including program/project budgets preparation, record reconciliation, quality assurance, and inventory of aircraft tool room. Organized the schedule of vehicle usage based on priority, supply, and demand, while ensuring strict compliance to all DOT regulations. Facilitated training on proper use of vehicles and flight line equipment as well as OSHA requirements and material safety data sheets. Carried out periodical inspections of hazardous waste collection sites.

  •  Designed, developed, and implemented a database tracking system that efficiently monitor and maintain tools and test equipment valued at $5M

Assistant Administrator/Music Director (Volunteer Position)
STUV School § Colorado Springs, CO | 1998-2004

Assumed administrator’s responsibilities in her absence; developed and managed the budget for the school’s funding and supplies; and developed the customer/student-parent complaint resolution process. Designed and developed a music program, and taught them to student in the band at all levels.

  • Consistently delivered safe and productive learning school environment through establishing positive relationship with students, teachers, and parents.

Other Experience

Medical Technician/Medical Evaluation
United States Air Force Reserve/Guard | Berry Field, Nashville, TN | 1997–2000 | 2007–Present

Bus Operator
Company Rstuv | Colorado Springs, CO | 1997-2004
Company Pqr| Colorado Springs, CO | 1995–1997

Other Credentials

National Registry of Emergency Medical Technicians (EMT), 1998
United States Air Force Medical Training | Sheppard AFB, TX

Certificate of Training, 1994
United States Air Force Information Management Training | Fairchild AFB, WA

Certificate of Training, 1991
United States Air Force Aircraft Maintenance Training | Sheppard AFB, TX

Professional Affiliation

Project Management Institute (PMI)

Technical Skills

Microsoft Office Suite

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