Billing Specialist resume example with 20+ years of experience

(555) 432-1000,
Montgomery Street, San Francisco, CA 94105

20 years + in Medical Healthcare Claims Revenue Cycle. Focused and dedicated insurance professional motivated to provide superior customer service, exceptional organization skills. Great analytical and problem solving abilities.

Nashville State Technical Institute Nashville, TN Expected in 1981 Associate of Science : Business Data Processing - GPA :
North Nashville High School Nashville, TN Expected in 1978 High School Diploma : Math - GPA :
Archway Marketing - Billing Specialist
Strongsville, OH, 2012 - 08/2014
  • Verifies insurance benefits via multiple web portals and phone calls.
  • Work closely with insurance carriers for reimbursement requirements to ensure payment.
  • Follow up on denials and claim status.
  • Confirm coordination of benefits via web portals and phone calls.
  • Follow up and/or complete 65 – 100 outstanding AR accounts a day.
  • Identify top market issues weekly.
  • Reconcile unpostables on a weekly basis.
  • Reduced AR amount by significantly during the month of August-September by identifying billing error in which provider was loaded incorrectly. Created spreadsheet to identify patients and providers affected. Worked closely with internal Provider Enrollment department and Payer Provider Relations department to resolve issue.

Retained [<Number>]% of policyholders during annual renewal period.

Aaa Of Southern California - Claims Examiner
Wentzville, MO, 08/2014 - Current
  • Provide accurate and timely processing of direct contract claims per regulatory and contractual guidelines.
  • Adjust claims for Tenncare including complex claims, determine prior authorization/precertification of services paid via system and/or health services, and review claims for required information, pending claims when necessary, maintain a follow-up system, and update and release pending claims when indicated.
  • Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials (PDR, CPT, ICD-9, and HCPCS), and complete product and Coordination of Benefits.
Amita Health - Technical Claim Specialist
Melrose Park, IL, - Current
  • Reviewed Worker's Comp PPO claim disputes.
  • Utilized multiple systems such as state fee schedules, RBRVS and other payer specific systems to verify provider's contracts.
  • Notified clients regarding resolution via written communication.
  • Consistently exceeded Quality standards of 95%.
  • Helped to streamlined use of multiple verification systems by suggesting we utilize our new in-house database to verify provider's contracts.
Amita Health - Quality Control Specialist/Refund Integrity Specialist
Mesa, AZ, 08/2010 - 2012
  • Successfully reviewed over 32 accounts per day to determine the validity and accuracy of refund.
  • Analyzed and interpret various credit balance transaction statements, various payer systems-coverage, reimbursement, COB data and EOB content
  • Reviewed 837I and 837P forms for purposes of gathering information.
  • Provide constructive feedback to Provider Service Analyst.
  • Assisted with identifying and reporting error trends
  • Received Certified Patient Account Technician (CPAT) certification.
HCA - Provider Enrollment Specialist
City, STATE, 11/2009 - 01/2008
  • Managed the completion and submission of provider enrollment applications.
  • Performed tracking and follow-up to ensure provider numbers were established and linked to the appropriate HCA Physician group entity in a timely manner.
  • Detailed knowledge of specific application requirements for each payer including pre-requisites, forms required, form completion requirements, supporting documentation (DEA, CV, etc.), and regulations.
  • Maintained documentation and reporting regarding provider enrollments in process.
  • Retain records related to completed provider enrollments.
  • Worked closely with practice site managers to expedite completion of forms and requirements including obtaining signatures, locating required documentation, etc.
  • Ensured that established provider numbers were communicated for entry into billing master files in order to release pended claims.
  • Maintained provider enrollment information within the credentialing database.
Cigna - Business Analysis Sr. Associate
City, STATE, 06/2005 - 08/2007
  • Analyzed system requests per Medical Director and Nurses.
  • Updated, changed and created audits and edits per submitter's request.
  • Performed regression testing for all system changes on a timely basis.
  • Documented and updated Microsoft Excel and in-house database.
  • Completing CMS change requirements within specified turnaround time.
  • Consistently met turnaround time of 10 days for completing system requests.
  • Ensured work processes were compliant with governmental regulations and company policies and procedures.
Cigna - Provider Enrollment Specialist
City, STATE, 05/2001 - 06/2005
  • Enrolled providers in the Medicare program by processing Medicare 855B, 855R and 855I applications.
  • Reviewed application for correctness.
  • Requested supporting documentation such as DEA, CV, Medical Licenses, etc.
  • Issued provider number and added provider to system for billing purposes.
  • Sent provider notification letters to provider.
  • Updated and maintained enrollment information in provider enrollment's in house database.
Cigna - Sr. Adjustment Specialist, Lead Benefit Analyst, Appeals Specialist/COB Specialist/Claims Examiner
City, STATE, 1991 - 05/2001
  • Processed adjustments for 10 health plans in a 45 day turnaround time.
  • Acted as a liaison between the customer call center and Adjustment Specialists.
  • Developed interdepartmental forms for the adjustment team.
  • Trained new Adjustment Specialists and temporary employees.
  • Processed urgent adjustment requests and investigations in a timely manner.
  • Organized meetings and scheduled conference rooms for customer call center.
  • Assisted the Quality Auditors in identifying areas of training for Benefit Analysts.
  • Researched to determine validity of appeal and communicated outcome via formal letters.
  • Responded to phone inquiries from providers and beneficiaries.
  • Educated provider regarding correct billing of Medicare claims.
  • Processed and calculated Medicare Secondary Payer claims.
  • Determined correct medical procedure codes for services rendered for claims received on CMS 1500 forms.

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Resume Overview

School Attended

  • Nashville State Technical Institute
  • North Nashville High School

Job Titles Held:

  • Billing Specialist
  • Claims Examiner
  • Technical Claim Specialist
  • Quality Control Specialist/Refund Integrity Specialist
  • Provider Enrollment Specialist
  • Business Analysis Sr. Associate
  • Provider Enrollment Specialist
  • Sr. Adjustment Specialist, Lead Benefit Analyst, Appeals Specialist/COB Specialist/Claims Examiner


  • Associate of Science
  • High School Diploma

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