Claims Specialist Quality Manager

Evelyn Smith

**** ********* ** *******, ** ***** 708-***-**** *********@*****.***

Professional Summary

Enthusiastic individual, with 22 years’ experience in claim technical/functional support to appropriate line of business. Bringing to the table the ability to combine knowledge, ethics, personality and adaptability to any challenge. Verifiable track record for the successful completion of projects through developing partnership and building positive rapport with team and business partners and able to learn new tasks quickly and proficient.

Skills, Knowledge & Abilities_

Strong attention to detail and knowledge of claims and insurance industry theory and practices products, technology, procedures and systems across lines of business.

Strong knowledge of Microsoft Office suite and other business related software.

Strong attention to detail, verbal, written, analytical, presentation and interpersonal skills.

Strong organizational skills with the ability to manage multiple tasks and work independently managing time and resources to accomplish multiple tasks and meet deadlines.

Experience

Quality Assurance Rep – Quality Control & Learning

CNA Insurance – Lake Mary, FL Oct 2017 – Present

Review and evaluate Claim Operations functions and tasks for compliance with department procedures and regulatory requirements. Calibrates completed reviews with the Claim Operations Quality Manager, Claim Operations Quality Director and Process Analysts to identify best practice and opportunity areas.

Meet SLA guidelines in creating files, reconciling information, executing system batches, etc. by completing daily, weekly and monthly analysis, reports, and summaries to support audit, compliance and regulatory responsibilities.

Use business acumen and industry knowledge to provide input on the development of audit programs, tool, and SOX/SOC compliance and prepares both monthly and quarterly reports for management for testing and validation for various operations systems.

Analyze findings to make recommendations for improvement of each department's practices and procedures as well as enhancements to training while remaining externally focused.

Provide management reports, indicating findings, trends and recommended corrective actions to enhance quality and productivity. Accountable for being a resource as it pertains to questions related to standard work practices.

Strong interpersonal, communication skills. Ability to effectively interact with all levels of CNA's internal and external business partners.

Periodically serves as support for the Claim Operations Quality Director by providing additional context to review results, supporting action plans for the business teams and partnering with the Claim Operations Process Analysts on employee training and process improvements.

Responsible for input of data that accurately reflects claim circumstances and other information important to our business outcomes. May provide guidance and assistance to other claims staff and functional areas for opportunities.

Assist with auditing by gathering material from each line of business and submit to our auditors for review.

Assist with setting up medical malpractice cases into the National Practitioner Date Base.

Claim Operations Technician – Cashiers Team Feb 2016 – Oct 2017

CNA Insurance – Chicago, IL

Completed/Created job aids, forms, letters, and documents timely in accordance with regulations and service level agreements.

Completed data or makes data corrections based on set requirements or procedures utilizing multiple claim systems that support P&C Claim.

Performed various financial transactions such as paying bills, payment transfer, wire transfers, direct deposit, etc. utilizing set procedures and guidelines.

Made contact to underwriting, insured’s, claimants, providers, vendors or claim adjusters utilizing various methods to obtain and provide information related to claim support activities.

Served as day to day resource for procedural or process questions. Assisted as a Quality Reviewer for check handlers using AIM Tool.

Reviewed and reconciles reports for data or financial transactions related to claims.

Completed special projects as necessary and strong interpersonal, communication and negotiation skills. Ability to effectively interact with all levels of CNA's internal and external business partners.

Property Claims Specialist May 2000 – Feb 2015

Hartford Insurance Aurora, IL

Strong attention to detail and knowledge of claims and insurance industry theory and practices products, technology, procedures and systems across lines of business.

Strong excellent focus on customer service and resolving coverage issues, ensure claim files are properly documented and set activities, reserves and authorizes payments within scope of authority. Ensure issuance of disbursements while managing loss costs and expenses. Using appropriate cost containment techniques, including strategic vendor partnerships to reduce overall cost of claims for our clients.

Coordinates and performs investigations and evaluates claims and suits through contact with attorneys, account representatives, agents, public adjusters, contractors and insureds to develop a focused strategy for timely and cost effective resolution of more complex claims insureds, claimants, business partners, witnesses and experts. Seeks early resolution opportunities. Identifies files that have potential fraud and refers to SIU.

Monitored 300+ claims for holdback, conducting ongoing investigation, damage verification, estimating, valuation and timely settlement in the final disposition of all claims assigned.

Negotiate settlement packages regarding claims with attorneys, public adjusters and contractors. Calculate approve, make timely claim payments and assign timely appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.

Communicated claim activity process with the claimant and the client; maintained professional client relationships and ensure claim files were properly documented and claim coding is correct.

Resolved coverage issues, solid experience with managing and prioritizing heavy workloads, adjusting claims from 0.00 to 250,000.00, led unit in subrogation referrals and non-weather related perils for commercial property (i.e. theft, vandalism, accidental discharge, vehicle impact, business interruption).

Education

Bachelor of Science: Business Administration Expected Graduation Date Open

Concentration in Health Services Information Management

DeVry University Chicago, IL

Achievements/Community/Company Involvement

Attendance Awards Manager On-The-Spot Recognition

Employee-To-Employee Recognition Focus groups for 2012 strategic initiatives

Mentorship for new hires Volunteer Aurora Philanthropy and Field Giving Committee

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