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Skills

  • Collaborating with legal and regulatory agencies
  • Customer dispute resolution
  • Familiar with fraud statutes
  • Detailed fraud reporting and case management
  • CCC Pathways
  • Conflict Resolution in Disputed Claims
  • High-volume claims management
  • Claims intake and documentation tools (Power BI)
  • Fair Isaac Claims Advisor
  • Personal, casualty and property loss

Work Experiences

  • Bolstered the credibility of the firm's investigations.
  • Maintained a suspicious claims database and prepared supervisory reports on a the past year basis.
  • Fixed program codes so that system claims could be properly classified.
  • Worked with the claims department and industry anti-fraud organizations to resolve claims.
  • Examined claim forms and other records to determine insurance coverage.
  • Was in charge of directing and coordinating the field investigation team's investigations.
  • Automated procedure reporting processes.
  • Closed 4 cases by the end of Qprocedure.
  • Reviewed new files to determine the current status of an injury claim and devise a strategy.
  • Automated documentation processes.

Summaries

  • Claims Investigator is a multi-talented Claims Investigator who is consistently rewarded for planning and operational improvements.
  • Detailed Adjuster with 6 years of corporate insurance claims experience.
  • Excellent track record of resolving issues, increasing customer satisfaction, and driving overall operational improvements.
  • Automated metric workflows.
  • Proven leadership, operational excellence, and organizational development skills, as well as a thorough understanding of the method business.
  • Claims Examiner with extensive experience in the standard claims industry.
  • Achieved 80% improvement in claim processing accuracy.
  • Claims Investigator with a passion for personal, property, and casualty losses and damages.
  • Consistently met deadlines.
  • Achieved improvements through cross-department collaboration.

Accomplishments

  • Prepared detailed reports and presentations for senior management on claim trends and risk assessment findings, driving strategic decisions.
  • Identified 28% more fraudulent claims by introducing machine learning algorithms into claims analysis processes.
  • Utilized Excel, ServiceNow, and other tools to prepare audit-ready summaries of complex claims, improving compliance readiness by 27%.
  • Participated in cross-departmental projects to establish best practices in handling contested claims, resulting in $17 savings.
  • Reviewed and audited 12-claim files per month and identified 39% in cost-saving opportunities.
  • Reduced invalid claim settlement costs by $4 through the integration of enhanced verification tools and data insights.
  • Reduced claims processing costs by $12 by optimizing the verification and auditing techniques within the department.
  • Achieved OSHA certification to enhance investigation techniques and meet industry standards in claim handling protocols.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.
  • Collaborated with team of 6 in the development of program.

Affiliations

  • Insurance Fraud Association Conference Attendee (2016)
  • Insurance Accounting and Systems Association (IASA)
  • Certified Insurance Counselor (CIC) active status
  • Fraud Alliance (Phoenix)
  • Property and Casualty Claims Professionals (PCCP)
  • Toastmasters
  • Certified Legal Investigator (CLI) Membership
  • National Association of Insurance Commissioners (NAIC)
  • American Bar Association – Insurance and Claims Division
  • Association for Supply Chain Management (APICS)

Certifications

  • Salesforce
  • CompTIA Network+
  • Certified Business Analysis Professional (CBAP)
  • Certified Anti-Money Laundering Specialist (CAMS) - method
  • Certified Ethical Hacker (CEH) - EC-Council for Cyber/Insurance Fraud Investigations
  • Certified Financial Crimes Investigator (CFCI) – International Association of Financial Crimes Investigators (IAFCI)
  • First Aid/CPR Certified
  • Workers' Compensation Claims Professional (WCCP) - American Institute for CPCU
  • SHRM Certified Professional (SHRM-CP)
  • Certified Information Systems Auditor (CISA) - process

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