Analyst, Claims Resume Sample

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Mavis Mayert
56622 Martine Land,  San Francisco, CA
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Work Experience

Senior Claims Encounter Analyst
04/2016 - PRESENT
Los Angeles, CA
  • Gathers data and structures reporting to service business needs
  • Completes full root-cause analysis on inventory issues and develops action plan
  • Designs and manages staff scheduling system
  • Creates and implements inventory reduction plans
  • Identifies and communicates issues or unusual trends in inventory
  • Manages resources based on inventory need; updates schedules
  • Establishes a set of scheduling resources and monitoring systems to manage schedule administration, communication, and track performance
  • Ensures assigned work is complete
Claims Quality Analyst
09/2012 - 01/2016
Los Angeles, CA
  • Conducts meetings with operations leadership to discuss strategy, issues, and results
  • Empowers processing teams through training and knowledge sharing
  • Develops and provides presentations for leadership
  • Gather data and structures reporting to service business needs
  • Complete full root-cause analysis on inventory issues and develops action plan
  • Design and manages staff scheduling system
  • Create and implements inventory reduction plans
  • Establish a set of scheduling resources and monitoring systems to manage schedule administration, communication, and track performance
Analyst, MI & Conventional Claims
03/2007 - 03/2012
Philadelphia, PA
  • Work in a fast paced cal
  • Six months or more of customer service experience
  • Independently manages Workers’ Compensation indemnity claims for the Company within an assigned geographical area ensuring compliance with applicable jurisdictional rules and regulations
  • Monitors progression of injured employee’s progress to achieve optimum medical recovery and expedient return to work. Coordinates return to work ensuring that appropriate communication takes place with TWC business partners and ensures that the employee is returned safely to work within their restrictions (if any). Maintains contact with injured employee
  • Conducts weekly quality assurance review of member explanation of benefits (EOBs) and provider’s Remittance Advice (RA), provides vendor feedback to the Claims Manager, as necessary
  • Oversight of all casualty claims from day one to resolution
  • For Workers Compensation claims, conduct claims audits; follow up with location management to ensure transitional Duty positions are available


Strayer University - Owings Mills Campus
2001 - 2006
Bachelor's Degree in Information Systems

Professional Skills

  • Excellent communication skills, both verbal and written, with all levels of the organization
  • Demonstrated ability in functioning effectively in a collaborative team environment
  • Demonstrated knowledge of state and federal laws, medical and legal terminology and best claims practices. Preference for New York City experience
  • Prior analytical experience in a business environment
  • Prior experience in a transactions based operation
  • Prior knowledge/experience with account based products
  • Demonstrated ability in handling complaints, resolving conflicts and negotiating with others

How to write Analyst, Claims Resume

Analyst, Claims role is responsible for design, database, excel, compensation, mainframe, training, auditing, litigation, reporting, research.
To write great resume for analyst, claims job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Analyst, Claims Resume

The section contact information is important in your analyst, claims resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Analyst, Claims Resume

The section work experience is an essential part of your analyst, claims resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous analyst, claims responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular analyst, claims position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Analyst, Claims resume experience can include:

  • Expedite medical treatment for early RTW efforts, answer WC benefit questions from injured workers and management, manage workers' compensation claims administration process
  • Excellent computer skills (e.g handling of various Tools, Software, etc), including proficient MS Excel and database management
  • Effective writing skills for documentation of requirements and system design documents
  • Good understanding of costs associated with war zone related trading
  • Self-motivated with good drive and enthusiasm; independent working style requiring minimal direction & supervision
  • Working experience in claims processing quality or appeals and grievances

Education on an Analyst, Claims Resume

Make sure to make education a priority on your analyst, claims resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your analyst, claims experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Analyst, Claims Resume

When listing skills on your analyst, claims resume, remember always to be honest about your level of ability. Include the Skills section after experience. Present the most important skills in your resume, there's a list of typical analyst, claims skills:

  • Communicates clearly and effectively with multiple levels of staff
  • Experience analyzing and solving customer problems in an office setting
  • Experience in claims operations, inventory management, scheduling and forecasting in a claims or call center environment
  • Cosmos Claims Processing and Auditing Experience
  • Demonstrated ability to exercise proper judgment and decision making on all aspects of claims management
  • Experience interpreting provider contracts and benefits

List of Typical Experience For an Analyst, Claims Resume


Experience For Claims Quality Analyst Resume

  • Eager to learn and adapt to changes; capable to apply gained knowledge effectively
  • Analytical and connected mindset with strong flair for figures and statistics
  • Languages: Fluent and proficient in English (written/spoken); good knowledge in either German or French
  • Knowledge and experience in one or more functional areas managed through HealthRules Payor
  • Previous PBM experience
  • Working knowledge of debit/credit, banking regulations and Mainframe Applications(ex. BOSS/FAST)
  • Problem solving based on understanding of system capabilities and business need
  • On-going assessment and determine action warranted of medical providers
  • Generate after loss management ideas and bring them to execution

Experience For Senior Claims Encounter Analyst Resume

  • Work in high volume environment, adhering to production standards and SLAs set by management
  • Claims handling support to claim experts in a broad range of classes, with a particular emphasis on Natural Catastrophes and Aviation/Agriculture
  • Develop new and build on existing reports for claims department and senior management
  • Provide support of vendors, managing SLA’s, regulatory requirements and contractual metrics
  • Maintains reporting infrastructure, as appropriate (e.g., SharePoint, Access databases)
  • Provides supporting documentation for audit findings

Experience For Claims Root Cause Analyst Resume

  • Identify, communicates and implement opportunities for improving internal audit/rebuttal processes within the Quality team
  • Optional/Ideal: affinitiy to mathematics and advanced algorithms, scripting & statistical language
  • Establish relationships with TPA/Attorney/Medical Provider/Safety Designates/Injured Workers
  • Run reports/analysis with analytical ability to spot and explain trends
  • Multi State Workers' Compensation, Auto Liability, and General liability Law Knowledge
  • Reviews/Ensures integrity of workers' compensation management systems
  • Support local execution of Employee Intervention Process
  • Responsible for claim progress, incurred dollars and credit/debit dollars
  • Claims coordinator for Catastrophic incidents

Experience For Senior Claims Quality Analyst Resume

  • For Liability claims, conduct claims audits and coordinate the claims process with TPA, Safety. and legal
  • Reviews/Ensures integrity of claim management systems
  • To understand the specific requirements from charterer's for required amendment in invoices and vet those requirements against contractual obligations (Charter party terms). Flagging the requirements appropriately to chartering/Finance/TBT (Tramos business team) and deal the issue with an action oriented approach
  • Review, research, investigate and audit claims and provide feedback to team members on audit results
  • Analyze and use information to build recommendations to reduce errors and improve process performance
  • Understands how his/her role relates to the business unit objectives
  • Review, research, investigate and audit claims and with focus on the Provider Contract setup and provide feedback to team members on audit results

Experience For Senior Claims & Risk Analyst Resume

  • Collect and analyse data of individual claims, events or portfolios
  • Manage risk or event losses in respect of exposure estimates, reserved and paid amounts
  • Handle large losses of multiple clients and contracts for various lines of business and other SCOR locations
  • Contribute to projects within the department and across the company
  • Assurance within the Claims job family. Conducts audits and provides feedback to reduce errors and improve processes and performance
  • Understanding of how claims payment methodologies, adjudication processing and State Encounter regulations interrelate to maintain compliant Encounter reconciliation processes and SLA’s
  • Coordinates and documents automation and enhancement requests across functional teams and departments, communicating with A&G programming teams
  • Conducts shadowing of multiple processes alongside automation teams to document business and compliance needs

Experience For Analyst, SIU Claims Resume

  • Learn new A&G tools functionality becoming familiar with all automation and reconciliation work
  • Assists with implementation follow up tasks of projects under the direction of management
  • Assists with project documentation and files
  • Coordinates meetings and follow up project work for receipt reconciliation activities
  • Performs detailed review, research, and investigation on business feedback related to A&G Tool and reconciliation across all M&R Appeals and Grievances teams. Responds to, and takes next steps as necessary for remediation. Provides comprehensive evidence and documentation of all requests
  • Performs queries on relevant claims systems in order to obtain relevant information for audits
  • Utilize data and algorithmic guidelines as defined by Advanced Analytics to identify potential anomalies, either pre or post pay

Experience For Analyst, MI & Conventional Claims Resume

  • Validates claims data, member data, provider data against information from claims processing or business processing systems to ensure that data/decisions/payment and recovery/settlement information is accurate
  • Analyzes claims/member/provider data against applicable policies and regulations to identify potential issues (e.g., member benefits, provider contracts, billing anomalies, payment accuracy, claims processing system issues, state mandates)
  • Reviews history of related claims to pull in and understand additional claims-related information
  • Calculates dollar amount of financial errors/defects
  • Develops and delivers fact-based audit determinations in an objective, non-confrontational manner
  • Escalates issues identified during the audit cycle or rebuttal process to applicable stakeholders, as appropriate (e.g., Subject Matter Experts, Operations Team, Quality Team, business partners, team leads)
  • Ensures compliance with applicable audit and rebuttal timelines (e.g., calibration timelines, rebuttal timelines/form completion, workflows, turnaround time)

Experience For Senior Analyst, Claims Resume

  • Achieves production quality goals/metrics (e.g., audits per hour, audit accuracy, first-pass accuracy, rebuttal accuracy)
  • Manages audit inventory to ensure proper workload balance, coverage and closure
  • Identify/communicate escalated errors/defects and ensure proper resolution, as needed (e.g., calibrations, rebuttals, appeals)
  • Location/Facility – Health Plan, Temple
  • Specialty/Department/Practice – Claims Cost Containment

Experience For Analyst, Workers Comp Claims Resume

  • Recommend claim settlements
  • Shift/Schedule – M - F 8-5
  • Comfortable with technological developments and use of multiple systems / applications
  • Broad system functional knowledge to be able to conduct an impact analysis
  • Specialty/Department/Practice –Claims Department

Experience For Senior Analyst, Bodily Injury Claims Resume

  • Casualty claim license required
  • At ease with structured, unstructured and incomplete data
  • Work effectively with others within the department, particularly with other claim experts and staff in technical accounting, finance, underwriting and actuarial units
  • Able to work collaboratively across teams
  • Make coverage decisions
  • Travel is less than 20%
  • Conduct insured visits
  • Diligent and thorough

List of Typical Skills For an Analyst, Claims Resume


Skills For Claims Quality Analyst Resume

  • Experience utilizing claims platforms such as UNET, NICE, Pulse, COSMOS, FACETS, and / or Diamond
  • Project coordination / management experience regarding claims payment and healthcare projects
  • Cosmos Provider Contract loading / Quality Experience
  • Demonstrate working knowledge of how to utilize and navigate PHYCON, Navigator and Emptoris for provider contracts
  • Good understanding of the verification process of contestability
  • Claims experience (preferably ATM/Debit)
  • Fraud experience (preferably ATM/Debit)

Skills For Senior Claims Encounter Analyst Resume

  • Able to prioritise urgent issues that need attendance
  • Experience in a Medical Claims environment
  • Experience with the Employer & Individual and Medicare & Retirement lines of business
  • Claims and/or quality experience
  • Medicaid or Medicare appeals and / or grievance experience
  • 1" year of Operations experience in Healthcare Industry
  • Healthcare and/or health insurance experience
  • Mortgage Insurance and/or Mortgage Servicing experience
  • Very good understanding required to grasp key contractual terms (charter party terms) with busi-ness intent

Skills For Claims Root Cause Analyst Resume

  • A-Level professionals with 3-5 Years of experience in claims processing
  • Working knowledge of applicable platforms across the varying lines of business noted. (M&R, C&S, E&I or Commercial)
  • Understanding of Risk and a delegated model
  • Working knowledge of Medicare & Retirement, Community & State, and Commercial payments, policies, procedures, and regulations
  • Attend mediations, monitoring trials and facilitating recoveries, insured visits, participating in file reviews and managing special projects as assigned
  • Previous exposure to recognizing, summarizing and reporting of trends and anomalies (on reinsurance market and claims activity)
  • To chase the outstanding, which have been delayed beyond due date, as per signed off chasing procedures

Skills For Senior Claims Quality Analyst Resume

  • To report weekly on the outstanding beyond certain days to chartering dept for further action
  • Flexible and willing to respond positively to change
  • Work in a client based environment meeting goals
  • Extended periods of sitting at a computer and use of hands/ fingers across keyboard or mouse
  • Obtain favorable adjudication following submission of Department of Defense form SF86
  • Monitor and provide direction to Third Part Administrators (TPA) handling claims for AIG companies and customers
  • License/Certification- Multi-state adjuster license required

Skills For Senior Claims & Risk Analyst Resume

  • Proficiency with Microsoft Office Suite (Word, Excel, Power Point) and email
  • Experience with Microsoft Office (Word - Creating documents / templates / lists; Excel - Data entry, sorting / filtering; Outlook - Send / receive email, create tasks, update calendar, set "Out of Office")
  • Experience with Microsoft Excel (sort data, create very basic tables and graphs)
  • Intermediate level of MS Excel and PowerPoint
  • Proficiency with computer and Windows PC applications, which includes the ability to navigate and learn new and complex computer system applications
  • Intermediate level of MS Excel (Sort & Filter data) and PowerPoint (create presentations)
  • Proficiency with Microsoft Word (creating and editing documents), Excel (general spreadsheet navigation, data entry and sorting), Outlook (email and calendar) and PowerPoint (creating and editing slides for presentations)
  • Communicate process failures and propose remediation, as well as developing remediation plans in all variety of mediums (verbal, writing, PowerPoint) to a broad audience level
  • Experience establishing rapport and credibility in order influence outcomes at all levels across the organization

Skills For Analyst, SIU Claims Resume

  • Benefit, Claim and/or Enrollment configuration experience
  • Experience identifying patterns within quantitative data, drawing conclusions and recommending solutions and approaches; skilled with end-to-end issue resolution
  • Large-scale platform implementation or migration experience
  • Experience within a matrix organization, healthcare or insurance company
  • Experience in the insurance field
  • Bilingualism; excellent knowledge of French and English
  • Devise and implement effective claim management resolution strategies
  • Accomplish cost effective litigation plans, negotiations, and resolution strategie

Skills For Analyst, MI & Conventional Claims Resume

  • Product, Benefit, Claim and/or clinical research and analysis knowledge
  • Knowledge of data structures within a health plan configuration system (e.g. Facets)
  • Clearly articulate (both verbal and written) project status and issues management
  • Experience in Microsoft Office skills including Word (create, edit, save), Excel (create, edit, save, plug in data, pivot tables, charts, Lookups), Outlook (send, receive, set appointments), and PowerPoint (create presentations of analysis)
  • Knowledge of applicable quality processes/approaches (e.g., Six Sigma, BPQM, ISO)
  • Responsibility for claim settlements <$50K
  • Approval of Workers’ Compensation cost containment measures to include the assignment of nurse case managers, subrogation, investigative measures and the approval of claim denials
  • Possess broad knowledge of varying Workers’ Compensation statues in multiple jurisdictions, including the terminology used in each and unique characteristics

Skills For Senior Analyst, Claims Resume

  • Casualty claim management experience
  • Maintain and handle confidential information
  • Acute business knowledge to allow proper management of claims requests
  • Available to travel if required
  • Review and analyze claims submitted by TPA’s
  • Complete independent analysis on assigned claims
  • Attend mediations, monitor trials and facilitate recoveries

Skills For Analyst, Workers Comp Claims Resume

  • Participate in file reviews and manage special projects as assigned
  • Effectively investigate and manage claims through the company’s third party administrator. This includes, but is not limited to, contacting, interviewing and reviewing records of injured employees, witnesses, attorneys, etc. to secure necessary information and evaluate compensability and settlement of claims by TPA
  • Reviews are focused on ensurng the TPA adheres to Best Practice claims management. The role is responsible for escalating of the TPA’s failure to demonstrate Best Practice claims management in any pending workers’ compensation claim
  • Oversee administration of all Workers’ Compensation, Auto Liability, and General Liability claims to include accident investigation involving considerable contact with business units, employee, claimants, third parties, vendors, and in house/outside legal counsel
  • Handling/oversight in workers’ compensation claims or related experience including a thorough knowledge of insurance, contractors, claims, and terminology
  • Validate claims files to permit their payment
  • Revise claims and provides recommendations to clients in the shortest possible delay
  • Offer support to clients in regards to group and individual insurance claims procedures

Skills For Senior Analyst, Bodily Injury Claims Resume

  • Communicate with clients to improve the quality of the information processed
  • Review and analyze claims submitted by TPA’s, making coverage decisions, completing independent analysis on assigned claims, devising, implementing effective claim management resolution strategies, accomplish cost effective litigation plans, negotiations, and resolution strategies
  • Calculation for Freight, TC hires, Miscellaneous (non-Demurrage) and Demurrage invoice in sys-tems (Tramos) for WS/Flat rate/Lump sums/etc and invoicing to charterers and / or via broker
  • Validate information from relevant parties (Vessel, broker, agent, chartering, vessel operation) to execute accurate Calculation in respective system
  • TAT based dunning and follow procedure for receivables
  • To accurately invoice charterers in a time bound manner upon receiving request from commercial ops
  • Create accurate revenue Invoices basis contract of fixtures and bill to customers
  • To do the sanity checks of the supporting and statements received from Vessel/agents and en-sure that they are as per the CP (contractual) terms. In case of changes required, same has to be flagged to them in order to receive the correct statements/documents

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