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Special Claims Adjuster / Specialist Resume

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Little Rock, AR

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SUMMARY:

Seeking a challenging position with a progressive local company. Individual who strives to excel, fulfill responsibilities, and adapt quickly to changing needs. An energetic personality with a strong grasp of support and effective communication skills that will be an asset to your organization.

TECHNICAL SKILLS:

  • TCP/IP & LAN/WAN Protocols
  • Network Technology
  • Windows 7/98/2000/XP/Professional
  • Vista/HOD
  • Windows Server 2003/ 2008
  • Linux
  • Visual Basic
  • VMware
  • Amisys Release / mainframe
  • HealthAxis
  • Palm/Handheld Devices
  • PC’s / Printers
  • Microsoft Word, Excel, PowerPoint, Access, Outlook, Publisher, Visio
  • Adobe Photoshop
  • Install, configure and troubleshoot
  • Remote Access
  • Phone and e - mail support
  • Documentation

PROFESSIONAL WORK HISTORY:

Confidential, Little Rock, AR

Special Claims Adjuster / Specialist

Responsibilities:

  • Utilize analytical skills to process and analyze medical, dental and vision claims for correct payment
  • Review edits with CPT manual
  • Verify Provider Networks, send for pricing if need to be
  • Obtain medical documentation from the Provider
  • Develop policy and procedures
  • Maintaining and assuring accuracy of documentation
  • Meet or discuss with clients, members and provider regarding claim issues
  • Proven ability to work in a multi-task fast paced environment
  • Distribute and prioritize of individual work flow
  • Supervised and lead on special projects
  • Manage subrogation and adjustment reports

Confidential, Little Rock, AR

Sr. Special Claims Adjuster

Responsibilities:

  • Utilized analytical skills to adjust and analyze claims for correct payment
  • Determined all pend and adjustment codes, while utilizing and processing manuals
  • Reviewed Utilization Review edits resulting in 95% accuracy rating
  • Studied, interpreted and applied health benefits for over 100 clients daily
  • Researched problems utilizing systems and processing manuals related to benefits and accumulators
  • Served on in-house committee to further employee interests
  • Developed and implemented policies and procedures
  • Supervised and lead on special projects
  • Audited claims examiners for accuracy and completion

Confidential, North Little Rock, AR

Sr. Claims Representative

Responsibilities:

  • Analyzed and processed an average of 150-200 Indemnity and Medical Workers’ Compensation Claims on a daily basis
  • Established an understanding of insurance contracts/policies
  • Managed litigation with direct counsel and directed nurse case managers on files
  • Maintained E-bills, E-invoices and maintained a 100% closing ratio of claims
  • Scored 90% or better on client and company audits over three year period
  • Submitted detailed status and control loss reports daily using excel spreadsheets
  • Investigated employee claims, contacted all parties involved, addressed reserves for the lifetime of claim, and obtained litigation plans and budgets
  • Organized, prioritized and multi-tasked independently with minimal supervision

Confidential

Claims Adjuster

Responsibilities:

  • Processed complex or technically difficult medical and indemnity Workers’ Compensation, General Liability and Property claims
  • Determined benefits due; made timely payments and adjustments
  • Obtained employee job description to discuss prompt return to work status
  • Interpreted medical reports; established and monitored reserve adequacy
  • Managed subrogation with third party on necessary claims

Confidential

Claims Clerk/Adjuster

Responsibilities:

  • Analyzed and processed medical-only Workers’ Compensation Claims for over 100 clients daily
  • Interpreted ICD-9 and CPT Codes and researched Arkansas laws and regulations
  • Maintained and assessed annual loss summary, month end, and state reports
  • Transcribed recorded statements for use in legal action
  • Attended quarterly continuing education classes and conferences
  • Documented new members, premium billing, and created deposits as a result

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