Claims Operations Resume Sample

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Dino Leannon
79023 Drew Highway,  New York, NY
+1 (555) 563 2056

Work Experience


Claims Operations Manager
05/2016 - PRESENT
Dallas, TX
  • Oversee Centene’s Sarbanes Oxley Risk Control Audit Process for the Business Operations organization,
  • Lead the North America Claims Operations team supporting the region, including providing performance management, quality review, and day-to-day guidance, training and mentoring in support of colleagues’ professional development
  • Makes and maintains a connection with the customer by understanding and meeting their needs; serves the customer with empathy; and follows up to ensure that customer needs have been me
  • Handles claim files (locates/requests files, files paperwork, moves misfiled documents, sends to other offices, etc.)
  • Manage overall quality, productivity and outcomes of medical/healthcare claims processing team
  • Manage team in a fast-paced, SLA driven environment
  • Manage day to day operations of group
Delegated Authority Claims Operations Analyst
04/2012 - 01/2016
Dallas, TX
  • Reviewing claims for using benefit rules to apply for medical claims or durable medical equipment experience required
  • Strong understanding of the Lloyd’s Coverholder Reporting Standards User Guide
  • Experience with delegated underwriting authorities ideally within the Lloyd’s market
  • Takes initiative to research and resolve escalated claims issues. Partner with other departments when necessary to resolve issues
  • Maintain and continue to develop knowledge of the various systems, and processes and procedures required to provide cost effective oversight and continuous improvement
  • Research, identify and obtain data / information needed to help process claims or resolve claims issues (e.g., verify pricing, prior authorizations, applicable benefits)
  • Client-facing interaction with the state
Admin Assistant, Claims Operations
02/2007 - 01/2012
Dallas, TX
  • Direct management of 15-20 employees including performance, adherence to policy, handling Protected Health Information
  • Participate in customer calls to resolve questions or inquiries
  • Handle escalations from Call Center
  • Participate or lead a Six Sigma project
  • Third party claims management experience in healthcare industry
  • Direct people management
  • In healthcare/medical claim processing

Education


Herzing University - Kenosha Campus
2002 - 2007
Bachelor's Degree in Business

Professional Skills


  • Demonstrated strong training, coaching, mentoring skills
  • P&C claims leadership experience with proven coaching and development skills
  • P&C leadership experience with proven coaching and development skills
  • Navigate systems tools and screens efficiently and effectively (e.g., keyboard skills, macros, shortcuts)
  • Experienced leader in recruiting, managing, building, and retaining an effective team of experienced professionals
  • Demonstrated leadership experience to include New Employee Team Coaching(NET), mentoring/developing/coaching employees, Pulse
  • Demonstrated ability to work effectively under pressure and within a collaborative team oriented environment using sound judgment in decision-making

How to write Claims Operations Resume

Claims Operations role is responsible for development, leadership, coaching, p&c, training, claims, insurance, compensation, mentoring, government.
To write great resume for claims operations job, your resume must include:

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

Contact Information For Claims Operations Resume

The section contact information is important in your claims operations 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 Claims Operations Resume

The section work experience is an essential part of your claims operations 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 claims operations responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular claims operations position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Claims Operations resume experience can include:

  • Responsible for all aspects of performance including coaching and development, career progression, employee engagement and effective communication
  • Leading and mentoring direct reports and providing them with coaching to ensure they reach their full potential
  • Leading and inspiring the Operations Team to ensure delivery of targets
  • Identifying and mitigating risks within the Operations Team
  • Working with Return to Work South Australia (RTWSA) to ensure all key deliverables have been met
  • Providing strategic direction as part of the South Australian Leadership Team

Education on a Claims Operations Resume

Make sure to make education a priority on your claims operations resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your claims operations 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 Claims Operations Resume

When listing skills on your claims operations 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 claims operations skills:

  • Strong presentation skills (phone and in person)
  • Superb interpersonal skills including verbal and written communications
  • Develop and provide claim management training and education resources for staff to increase their skills and competencies
  • Trong experience in Xactimate and Xactalalysis
  • Excelled verbal and written communication skills
  • Experience with Microsoft Office including Outlook and Excel

List of Typical Experience For a Claims Operations Resume

1

Experience For Claims Operations Manager Resume

  • Collaborates with other leaders to ensure ERMG operations are integrated and providing effective and efficient services to stakeholders
  • Experience working with healthcare customers finance team related to claims payment and recovery operations
  • Experience working with healthcare customers to ascertain, understand and meet their business needs
  • Examples include balancing work and life; balancing strategic and tactical focus; intellectual horsepower
  • Delivers prompt service to our clients by approving and processing payments on the basis of technical file reviews, and within settlement authority
  • Corresponds with clients and brokers on specific claim situations involving payments, reserves, and index calculations
  • Oversees all claim banking and reconcilement activities. Works directly with banks, Cash Management, Stat, Reconcilement, BRMS, clients and claim offices
  • Assists with the negotiations, documentation, planning and entry of all take-over claims
2

Experience For Manager, Claims Operations Resume

  • Participates in Claim Department Disaster Recovery Planning and implementation efforts
  • Provides support for all coding and suspense file corrections
  • Responds to client RFP's for info and pricing as requested
  • Apply knowledge of customer service requirements to process claims appropriately (e.g., Service Level Agreements, performance guarantees)
  • Communicate and collaborate with external stakeholders (e.g., members, family members, providers, vendors) to resolve claims errors / issues, using clear, simple language to ensure understanding
  • Collaborate with internal business partners to resolve claims errors / issues (e.g., Subject Matter Experts, Network Management, IT / systems staff, Compliance, vendor management teams, contract teams)
  • Develops annual budget for claims operations and is accountable to achieving stated financial results
  • Understands and can apply financial principles to business decisions; understands income statements, balance sheets, free cash flow, profit vs. cash. Understands the impact of their decisions on CHI’s balance sheet and income statements. Can coach direct reports around financial issues
  • Knows how the functions of a business work and relate to each other; knows the impact of business decisions; knowledgeable in current and possible future policies, practices, trends, technology and information affecting his/her part of CHI
3

Experience For Director of Claims Operations Resume

  • Has the expertise, knowledge and skills required to perform in his/her role and function at a high level of accomplishment; yet is not too narrow or does not depend upon technical and functional knowledge and skills at the expense of personal, interpersonal and managerial skills
  • HRA claims experience
  • Maintain solid relationships with clients, adjusters, lawyers and other Reinsures
  • Manage BPO services against Service Level Agreements (SLA's)
  • Prioritizes incoming claims correspondence and discuss complex losses with the Claims Manager, receives instructions and establish communication with the clients
  • Assumes responsibility on the losses under its own control
  • Establish and maintain claims reserves into the systems and processes payments within own and personal limits of authority
4

Experience For Claims Operations Manager / EDI Resume

  • Analyses claims information, reviews and asses the applicability of the reinsurance treaty / policy terms, and discusses the applicability of the reinsurance contract with the claims manager. Receives from the Claims Manager or Head authorization to pay losses in excess of its own authority limit
  • Creates claims files for facultative and excess reported losses, including establishing appropriate reserves, and refers the files to the Claims Manager
  • Maintains a dairy system to monitor activity on reported claims and takes appropriate follow-up measures
  • Provides claims services and technical support for assigned Line of Business and the systems managements
  • Group and Divisional claim reports for Latin America
  • Control and updates into databases for adjusters and lawyers
  • Providing day-to-day management, advice and support to the team through statistical analysis of internal and external management reports in line with the Victorian WorkCover Authority (WorkSafe) remuneration model
  • Understands the roles and relationships among provider network management, provider file operations, enrollment, and claims and designs the Cognizant solution based on the customers’ specific requirements, using products, services from the Cognizant portfolio and from third parties
  • Ensures Claims Operations adheres to all applicable state and Federal compliance related metrics and mandates; implementing corrective action plans for identified areas of non-compliance or error
5

Experience For Claims Operations Specialist Resume

  • Claims recovery operations experience including knowledge of recovery vendors
  • Recent and extensive experience with TriZetto Health Care Product’s Facets system
  • Healthcare management experience to understand the customer’s problems and how Cognizant’s capabilities address their requirements
  • Ensures that the Unit provides quality, timely and cost-effective services in support of internal and external clients and overall corporate goals
  • Collaborates with and defines and justifies a client specific solution for claims operations (in a global model)
  • Represents Cognizant Business Process Services as lead solution SME for interaction with customers for capability presentation, onsite due diligence, solution definition/presentation, knowledge transition, and ongoing service delivery management
  • Coordinates with client relationship teams and management teams to ensure the designed solution is serviceable in a cost effective way while meeting client SLAs and internal P&L goals
6

Experience For Delegated Authority Claims Operations Analyst Resume

  • Collaborates with all involved parties (global teams) to ensure that the solution is accurate to deliver outcomes to the client
  • Knowledgeable about current provider contracting methodologies (i.e. capitation, fee-for-service, DRG, etc.), and emerging technology, products and trends related to enrollment and billing
  • Selects, trains, and develops an effective/efficient staff. Establishes and communicates performance standards and objectives, conducts performance appraisals
  • Monitors operations and staff and recommends, when necessary, changes in methods, procedures, structure, and additions or changes in personnel to secure optimum utilization of resources and ensure efficient use of technology
  • Develops subordinate managers and/or supervisors, particularly in the management techniques of planning, organizing, leading and controlling; through continued coaching and feedback on performance
  • Oversees and assists with all necessary projects required and responds to all documentation requests. Reviews, approves and in many instances provides the supporting detailed business requirements
  • Oversees the processing of all buy-out, buy-back, Loss Portfolio Transfers and Trust Agreements and other specialty files at the direction of Broadspire clients
  • Leads in the development of creative approaches to solving technical and business problems to optimize usability by business customers and clients
  • Oversees all centrally processed payment and refund processing of various claim service provider fees
7

Experience For Claims Operations Lead Resume

  • Manages all claim administrative and data support services provided to Broadspire business units
  • Manages the production and maintenance of Risktech attachments, templates and form letters
  • Manages the Unclaimed Property process for the Claim Department
  • Manages the Claim Operations hot-line for all client and customer calls
  • Works collectively with internal and external business units to resolve any data transmission or procedure issues
  • Keeps VP Business Support Services informed verbally and in writing of activities and problems within assigned area of responsibility; refers matters beyond limits of authority and expertise to manager for direction
8

Experience For VP, Claims Operations Resume

  • Personnel Supervised: 10+ staff
  • Experience in insurance or information systems as well as project or general management experience or an equivalent combination of training and experience that would produce the following knowledge, abilities and skills
  • Displays excellent interpersonal skills
  • Excellent understanding of process and system flows
  • Demonstrates the ability to plan projects and manage resources to insure success results
  • Learns and changes quickly to respond to changing opportunities in the market place
  • Understands the impact of decisions, actions and technology on Broadspire’s and customers business systems
  • Displays ownership in business relationships and assignments
  • Clearly present information through the spoken and written word, reads and interprets complex information, talk with customers or clients; listens well
9

Experience For Head of Liabilities Claims & Claims Operations Resume

  • Stay well informed of current industry trends; learn and apply new concepts and identifies own areas of opportunity and sets and monitors self development goals
  • Demonstrate a high level of service delivery; do what is necessary to ensure customer satisfaction; deals with service failures and prioritizes customers needs
  • Challenge conventional practices; adapt established methods of new uses; pursues ongoing system improvements, develops new ideas to create solutions to problems, evaluates new technology as potential solutions to existing problems
  • Demonstrates or models behavior that rallies others around a common cause and builds a shared sense of purpose. Coaches and mentor others to develop their business competencies and technical skills. Provides support without removing responsibilities
  • P&C Management experience with proven coaching and development skills
  • P&C claims leadership experience with proven coaching and development skills
  • Strong Xactimate skills both UPP and Dwelling
  • Prior managerial experience (ex. someone who has lead and managed several employees)
10

Experience For Senior Claims Operations Manager Resume

  • Prior Military Officer or Staff Non-Commissioned Officer experience
  • Experience in handling UPP, Dwelling Claims and Liability
  • Managerial report writing experience
  • Experience handling complex injury claims
  • Experience handling litigated claims
  • Property Claims Adjusting Experience
  • Experience with CCC One estimating platform

List of Typical Skills For a Claims Operations Resume

1

Skills For Claims Operations Manager Resume

  • P&C leadership experience with proven coaching, mentoring and development skills
  • Intermediate keyboarding/typing skills
  • Demonstrated experience working in a fast-paced call center environment; to include working knowledge of call center tools and resources
  • Property claims field experience handling moderate to complex dwelling claims
  • Experience in analysing statistical information
  • P&C claims experience with positions of increasing responsibility
  • P&C insurance experience in any of the following: Auto, Property, Total Loss, Subrogation and/or Physical Damage
2

Skills For Manager, Claims Operations Resume

  • Experience in resolving escalated member complaints and conflict resolution
  • Proven ability to develop and set a strategy and an implementation plan
  • Any experience with a process improvement program (ie. Lean, Six Sigma etc)
  • High level of (Worker’s Compensation) Industry experience
  • Experience in Claims (Insurance Company)
3

Skills For Director of Claims Operations Resume

  • Reviewing, interpreting, and researching Explanation of Benefits (EOB's) and denial letter
  • Understanding of insurance carrier claims processing and knowledge of procedure and diagnosis coding (ICD, HCPCS, and CPT)
  • Developing staff and implementing quality initiatives within the business unit
  • Developing and interpreting management reports in line with the VWA remuneration model
  • Willing to relocate at your own expense (relocation is not being offered)
4

Skills For Claims Operations Manager / EDI Resume

  • Planning his/her own work together with the Claim Manager
  • Maximising performance through appropriate controls and customer service
  • Identifying opportunities to improve efficiencies
  • Planning its own work together with the Claim Manager
  • Ensuring the profitable and professional operation of activities
  • Identifying business opportunities for our company
  • Liaising with Victorian WorkCover Authority in all matters of contract
  • Delivering information sessions on Victorian Claims Management Model
5

Skills For Claims Operations Specialist Resume

  • Producing monthly reports of scheme indicators
  • Assessing present and future needs, trends, problems and profit opportunities within the Victorian workers compensation scheme
  • Analysing the profit performance of prospective clients, profit maximisation and our client profitability
  • Existing Field Physical Damage Spec
  • Ensure expertise or general claims support is provided to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims
  • Document and communicate status of claims / investigations to stakeholders as needed, adhering to reporting requirements (e.g., status letters / reports)
  • Manages all claim related activities surrounding centralized processing of all claim output
  • Managing leaders in an operational environment
  • Managing production and quality metrics
6

Skills For Delegated Authority Claims Operations Analyst Resume

  • Coordinates the corresponding activities and responsibilities on loss payments with the SSC and the Claims Manager
  • Analyze data, using various statistical methods necessary
  • Coordinates the corresponding activities and responsibilities on loss payments with the Claims Manager
  • Provides direction, support and resources to all Broadspire system related projects including enhancements, fixes and daily production support when necessary
  • Government programs, resources, legislation and mandates; examples include Affordable Care Act, Medicare, Medicaid, COBRA
  • High level of financial, business and commercial acumen, and the ability to analyze and interpret economic and market trends
  • Proven strong credibility with senior management and external customers and the ability to develop and build loyal customer relationships – demonstrated strong customer focus
  • Demonstrated experience in leading and managing people
  • A strong global awareness of cultural diversity
7

Skills For Claims Operations Lead Resume

  • Demonstrated self-starter mentality with an assertive “can do” attitude; ability to remove barriers
  • Customer Service\Call Center Experience
  • Third party claims management experience in a multiple payer environment in the healthcare industry
  • Upervisory / managerial experience in claims adjudication or customer service
  • Negotiate and influence with stakeholders internal and external to the firm
  • Experience in leading operations and / or business process improvement development and execution initiatives, integrating the voice of the internal and external constituents, preferably with a state Medicaid program
  • Working within the insurance industry and/or claims handling with any insurance product line
8

Skills For VP, Claims Operations Resume

  • Navigate within a Microsoft Windows environment
  • Intermediate Microsoft Office skills (including knowledge of formatting, editing, and creating documents in Word; pivot tables, V-lookups in Excel; and creating, formatting, editing PowerPoint
  • Upervisory / Managerial experience in claims adjudication or customer service
  • Travel about 10% (3-4 trips a year)
  • Administration and assignation of process and activities from Crew and Corflow (Triage)
  • Corflow administration of Mexican Insurance Company and production of reports for local regulators
  • Achieve applicable performance metrics (e.g., productivity, quality, TAT)
9

Skills For Head of Liabilities Claims & Claims Operations Resume

  • Use appropriate systems / platforms / applications to process claims
  • Use appropriate documentation, reference materials and / or websites to ensure that claims are processed accurately and efficiently (e.g., policy / procedure manuals, knowledge libraries, bulletins, training materials, databases, SharePoint sites, data warehouses)
  • Learn and use new systems / applications / resources as needed
  • Apply appropriate processes and procedures to process claims (e.g., claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents / certificates)
  • Leverage training resources to help apply claims processes / procedures appropriately (e.g., ULearn courses, coaches / mentors)
  • Apply knowledge of applicable laws, regulations and compliance requirements to ensure that claims are processed properly (e.g.,HIPAA, PPACA / Health Care Reform, state-specific regulations / grievance procedures, TAT)
  • Identify / develop / implement new claims processes procedures / solutions as needed, and document appropriately for future use (e.g., non-standard situations, special handling requirements)
  • Manage day to day site operations, leadership (internal and external to organization), and accountability for financial and non-financial results (budgets and actuals)
10

Skills For Senior Claims Operations Manager Resume

  • Provide oversight and authorization to ensure appropriate payment on claims occurs
  • Conduct analysis of quality trends and claim re-work; provides improvement plans as necessary
  • Positions in this function are responsible for performance guarantee attainment, contract compliance, regulations at the federal and state level, quality outcomes within established policies and procedures
  • Accountable for all property & casualty insurance claims management functions
  • Develops and achieves strategic goals consistent with ERMG/FIIL’s 5 Year Strategic Plan
  • Develop and implement best practices for claims management that protect the assets of CHI while working within the organization’s risk appetite and core values
  • Maintain a case based reserving policy that ensures accurate and consistent reserving practices (funding adequacy) for budgeting, financial reporting and underwriting requirements
  • Direct and provide oversight to staff to ensure that all claim functions (claim and litigation management, administrative and reporting) operate within CHI/ERMG policies, procedures and state and federal regulations

List of Typical Responsibilities For a Claims Operations Resume

1

Responsibilities For Claims Operations Manager Resume

  • Excellent Workers Compensation claims knowledge & technical skills
  • Experience handling catastrophe claims while deployed externally
  • Experience in client service role
  • Tertiary studies in appropriate discipline or equivalent knowledge gained through practical work experience
  • Experience in with Long Term Disability Insurance products (LTD)
  • Operations management experience (preferably claims operations)
  • Experience in with Short Term Disability Insurance Products (LTD)
2

Responsibilities For Manager, Claims Operations Resume

  • Seven years of experience in a management or supervisor role
  • Property claims experience
  • Strong desktop & time management
  • Current Property Claims Management Experience
  • USAA 1st party and/or 3+ years of 3rd party experience
  • Proven record of goal achievement and superior customer service
  • Physical Damage Appraisal experience
3

Responsibilities For Director of Claims Operations Resume

  • P&C insurance experience in Physical Property Damage
  • Auto claims industry experience
  • P&C claims multi-state auto experience
  • Achieving financial targets
  • Formal mentoring, coaching and IPAT support role or other special projects
  • Microsoft Office (reporting)
4

Responsibilities For Claims Operations Manager / EDI Resume

  • Currently posses or actively pursing an insurance designation (CPCU, AIC, SCLA, etc.)
  • Ability using systems
  • Develop rapport with others and recognize their concerns and feelings; builds and maintains long term associations based on trust; helps others
  • Interact with senior management team and other stakeholders
  • Adhere to appropriate response and turnaround times on project initiatives
5

Responsibilities For Claims Operations Specialist Resume

  • Teach, coach, and mentors others
  • Designs innovative business processes that support Information Technology solutions, create sustainable competitive advantage and administrative efficiencies
  • Provides assistance to less experienced analysts on a broad range of project management and process engineering disciplines to disseminate learning and promote the development of others
  • Ten years of experience in medical professional, general liability claims and complex litigation management
  • Handle claim files (locates/requests files, files paperwork, reconstructs missing files, moves misfiled documents, sends to other offices, etc.)
6

Responsibilities For Delegated Authority Claims Operations Analyst Resume

  • Retrieve, print, fax and mail supporting documentations to vendors or others as directed
  • Assumes full responsibility on the losses under his own control
  • Establish and maintain claims reserves in to the systems and processes payments within own and personal limits of authority
  • Work within a matrix organizational structure with multiple stakeholders
  • Collaborate with peers in other teams and functions
7

Responsibilities For Claims Operations Lead Resume

  • Work independently within a defined strategy and structure
  • Insurance Industry designation (ex. SCLA, AIS, AIC, CPCU, etc.)
  • ASE, I-CAR, technical certifications
  • AIC, ARM, SCLA, or CPCU designation(s)
  • Insurance designations such as AIC, ARM, SCLA, or CPCU designation(s)
  • MCS participant or graduate
8

Responsibilities For VP, Claims Operations Resume

  • Professional Certification(s)/Designation(s) (I.e. CPCU, SCLA, AIC)
  • Knowledge of Xactimate, Xactanalysis and Xact Contents
  • CPCU or other insurance industry designation
  • Knowledge of property claims contracts and interpretation of case law
  • Active Adjuster License
  • People management responsibilities to include: recruitment and hiring, maintaining staff workload balances, promoting teamwork, coaching claims staff to promote professional development, setting achievable individual performance goals, setting clear expectations and providing regular, ongoing feedback to staff as well as completing annual performance appraisals

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