Joe Jones
Richmond,TX
Summary
Experienced in conducting thorough investigations into suspicious claims, identifying fraudulent activities while ensuring compliance with industry regulations. Demonstrated ability to collaborate with law enforcement and legal teams, facilitating successful resolutions of complex claims disputes. Proven track record of managing multiple investigations simultaneously while maintaining detailed case logs and meeting strict deadlines. Skilled in navigating complex insurance claims and SIU investigations. Efficient in subrogation and underwritten referrals.
Skilled in navigating complex insurance claims and providing thorough investigations to ensure fair settlements. Have experience coordinating with legal teams, policyholders, and insurance companies to manage claims efficiently. Known for strong analytical skills, ability to interpret policy details accurately, and effective communication that results in resolved disputes. Made significant impacts by streamlining claims processing procedures, enhancing customer satisfaction through timely resolutions.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Auto Liability Adjuster
GEICO
Houston, TX
02.2023 - Current
- Evaluated auto insurance claims to determine liability and coverage.
- Communicated with policyholders to gather necessary information for claims processing.
- Investigated accident details by reviewing reports, photographs, and witness statements.
- Collaborated with legal teams to address complex liability issues during claims.
- Documented claim progress and resolutions in the claims management system.
- Negotiated settlements with claimants while adhering to company policies and regulations.
- Provided quality customer service to assigned, insured and claimants throughout claims process to deliver timely service to customers.
- Interviewed claimants, medical specialists, and employers to determine pertinent claim information.
- Reviewed police reports, witness statements, accident reconstruction reports and other documents related to an incident.
- Analyzed medical reports to determine the extent of injury or damage for bodily injury claims.
- Collaborated with colleagues from other departments such as Underwriting or Legal in order to resolve difficult cases quickly.
- Conducted thorough investigations of potential fraudulent claims and activities.
Inside Property Adjuster
AMERICAN FAMILY INSURANCE
Dallas, TX
09.2020 - 11.2022
- Evaluated property damage claims for residential and commercial properties.
- Reviewed policy coverage to determine claim eligibility and compliance.
- Conducted on-site inspections to assess property conditions and damages.
- Utilized claims management software for documentation and tracking purposes.
- Analyzed policy language to determine coverage availability or exclusion of losses.
- Assessed damages and evaluated repair estimates for accuracy.
- Negotiated settlements with claimants based on coverage limits and applicable laws.
- Explained loss coverage, assisted policyholders with itemizing damages and coordinated alternative living arrangements.
- Collaborated with contractors and vendors for repair estimates and assessments.
- Managed multiple claims simultaneously while ensuring timely processing of each case.
- Traveled to customer sites to evaluate fallen trees, leaking roofs and other issues to create accurate cost estimations.
- Investigated and evaluated property and casualty insurance claims to determine coverage and liability.
- Conducted water damage assessments to determine necessary mitigation actions.
Provider Claim Resolution Specialist
UNITED HEALTHCARE
Sugar Land, Texas
03.2017 - 07.2020
- Researched and resolved issues related to provider contracts, credentialing requirements, and reimbursement claims.
- Resolved complex provider claim disputes through effective communication and negotiation.
- Analyzed provider reimbursement requests for compliance with payer policies and procedures.
- Worked closely with providers to resolve pending claim issues and disputes.
- Monitored payment performance metrics such as turnaround time, denial rate.
- Reviewed and processed provider claims for medical services rendered to ensure accuracy of payments.
- Interpreted insurance contracts, fee schedules, plan benefits, eligibility requirements.
Customer Service Representative
BLUE CROSS BLUE SHIELD OF TEXAS
Houston, TX
10.2013 - 12.2016
- Assisted members with inquiries regarding health insurance policies and coverage options.
- Conducted follow-ups to ensure timely resolution of member issues and inquiries.
- Provided excellent customer service to resolve customer complaints in a timely manner.
- Maintained detailed records of customer interactions, transactions and comments for future reference.
- Managed renewal processes by reviewing policy details with clients.
- Researched relevant policy information to answer customer questions.
- Facilitated payment processing for premium payments and renewals.
- Assisted with resolving complex claims or billing disputes in a timely manner.
Education
HIGH SCHOOL DIPLOMA -
John Foster Dulles Sr. High School
Sugar Land, TxASSOCIATE OF APPLIED SCIENCE - ALLIED HEALTH
Fortis College
Houston, TxSkills
- Risk assessment
- HIPPA
- Subrogation
- Underwriting
- Auto claims
- Property claims
- Contents claims
- Water mitigation claims
- Liability determination
- Siu referrals
- Medical claims handling
- Customer service
- CRM
- Salesforce
- Xactimate
- Case management
- CPCU
- Medical terminology
- Uninsured motorist
- Underinsured Motorists
- Personal injury protection
- Medpay
- Bodily injury
- Medical coding
- Rideshare claims
Certification
Texas All Lines Property Adjuster License
Timeline
Auto Liability Adjuster
GEICO
02.2023 - Current
Inside Property Adjuster
AMERICAN FAMILY INSURANCE
09.2020 - 11.2022
Provider Claim Resolution Specialist
UNITED HEALTHCARE
03.2017 - 07.2020
Customer Service Representative
BLUE CROSS BLUE SHIELD OF TEXAS
10.2013 - 12.2016
HIGH SCHOOL DIPLOMA -
John Foster Dulles Sr. High School
ASSOCIATE OF APPLIED SCIENCE - ALLIED HEALTH
Fortis College