John Doe

Main Street, #1 | Anytown, CA 00000

T: 123-456-7890 | Email:

Insurance & Claims

Highly experienced and dedicated professional with expert proficiency in claims and insurance fields. Well-versed with various types of insurance and claims processes and policies. Adroit leader, capable of adequately managing a team of high-level specialists. Seeking further growth and development in a claims-related field, including but not limited to fraud, risk management, training and development, auditing and claims management. Oriented toward a senior-level position in an insurance company, provider or a patient-centered care organization.

Core Competencies

  • Initial and ongoing claims analysis
  • Knowledge of 13 claims policy types
  • Experience with Long-Term Care policies
  • Process weaknesses identification
  • Compliance with standards and flexible thinking
  • Training, coaching and mentoring
  • Team performance evaluation and management
  • Fluent proficiency in Spanish

Professional Experience

SOME INSURANCE COMPANY, Anytown, CA10/2010–present

Senior Claims Analyst

Lead a team of six Claims Analysts II, focusing on individual and team training, coaching and mentoring. Despite concentrating on team performance and development, continue reviewing cases with an average caseload of 35 claims. Maintain compliance with the standards and ensure achieving of productivity goals. Dissiminate information about changes in company policies or regulations, interview potential new-hires and conduct annual performance reviews. Perform secondary review of the claims denied by subordinates and cooperate closely with the Fraud Unit. Continue assisting the Audit Department with random file reviews (RFRs).

  • In February 2011 made adjustments to the 30-day floor training curriculum for new-hires, having increased performance ratings of two of the subordinates to company standard level. As a result, raised team’s overall quality rating to 98%.
  • Initiated a Quality-First Team principle, substantially contributing to improvement and maintenance of high quality ratings via “peer motivation” and “peer accountability” concepts.

SOME INSURANCE COMPANY, Anytown, CA07/2009–10/2011

Claims Analyst II

Inspected initial claims for eligibility, handling an average of 140 open cases of nine policy types in 10 states. Engaged in a more complex process of evaluation and review, verifying all supporting documents, contacting insureds and/or health providers to make inquiries about missing or incorrect information, and comparing the claims against the policy- and state-specific requirements. Depending upon the decision on the claim eligibility act according to the corporate policy and inform the supervisor in case of potential fraud.

  • Regularly assisted the Audit Department with RFRs and verification of the ongoing claims eligibility.
  • Within a year became the designated trainer/mentor of the unit.
  • Filled in for the supervisor for four months, overseeing 10 Claims Analysts II. Obtained an experience with the interviewing process and termination exit interviews.

SOME INSURANCE COMPANY, Anytown, CA10/2005–07/2007

Claims Analyst I

Served as a Claims Analyst I in the Long-Term Care (LTC) division, reviewing reimbursement requests on existing claims of 13 policy types. Processed reimbursement payments upon claim eligibility evaluation. On average handled approximately 175 open cases in up to 15 states. Identified potential fraud and escalated the claim with documented reasons of concern.

  • Assumed an increased regional responsibility, which was raised in July, 2006 from 10 states to 15 due to exceptional performance and excellent analysis and learning abilities.
  • Achieved and maintained 100% on-time reporting and quality rating, complying with all corporate and state-specific policy regulations.

U.S. Army12/2000–12/2004

Sergeant, E-5

Upon bootcamp completion served two deployments in Afghanistan and one in Iraq. During the latter received a promotion to Sergeant, E-5 and assumed responsibility for leading a unit of 10. Successfully performed as the squad head and cooperated with outsource security teams during combat missions.

  • The unit was awarded a Meritorious Unit Commendation in 2002.
  • Earned a Bronze Star in 2004.

SOME HEALTH CARE COMPANY, Anytown, CA06–08 / 1998, 1999

Summer Internship

Secured an internship in the Claims Department of a Level I Trauma Center of a regional scale and importance. Assisted with Accounts Receivable billing, reporting to the Claims Supervisor. Evaluated and processed claims from Medicare and various private insurance carriers. Having demonstrated an excellent grasp on the process, started working with denied claims as well, communicating via phone with patients and insurance carriers. Investigated denial reasons, billed patients for non-covered charges and resubmitted claims for payment upon correction of insurance information.

  • Developed an excellent accuracy rate of 96% within a month-and-a-half.

Having demonstrated exemplary performance, received an invitation to return for a second summer internship next year. To broaden knowledge and experience, specifically requested the other side of claims processing and in summer 1999 worked with the Provider Relations. Communicated with providers regarding denied claims, verified and corrected the diagnostic codes, handled patient billing and claims resubmission for payment.

  • Received a letter of recommendation from the second supervisor for “an outstanding grasp of claims processing and the ability to communicate effectively with patients, providers and insurance carriers”.

Education

UNIVERSITY NAME, Anytown, CA | 06/2000

B.S. in Business Administration | Major: Management | Minor: Information Systems

Honors & Awards

  • Awarded a $5K academic scholarship from Some Corporation | 06/1996
  • Vice President and President of high school Spanish Club | 1994-1996
  • Future Business Leaders of America Member