claim compliance analyst resume example with 4+ years of experience

(555) 432-1000,
, , 100 Montgomery St. 10th Floor
Professional Summary

Hardworking and passionate job seeker with strong organizational skills eager to secure entry-level Credit Specialist position. Ready to help Square Financial Services team achieve company goals.

  • Risk Identification
  • Critical Thinking
  • Time Management
  • Complex Problem-Solving
  • Good written and oral communication skills
  • Strong analytical skills
  • Understanding of developing new strategies for the prevention of loss
  • Above-average computer skills and knowledge of applicable computer applications
Strayer University Washington, DC Expected in 01/2023 Bachelor of Science : Information Science - GPA :
Ultimate Medical Academy - Clearwater Clearwater, FL Expected in 09/2020 Associate of Science Degree : Medical Insurance Billing - GPA :
Jefferson Davis High School Montgomery, Expected in 05/2015 High School Diploma : - GPA :
Work History
Hanger, Inc. - Claim Compliance Analyst
Santa Clarita, CA, 06/2022 - Current
  • Review and monitoring reports related to consumer and client activities.
  • Research 200+ claims for overpayment within assigned work que.
  • Work assigned claim according to book of business.
  • Attend weekly huddles and trainings trough WebEx.
  • Connect with different department thorough outlook to learn new ways to help the company grow.
  • Seek extra training to help with special team projects.
  • Prepare the process to return overpayments.
  • Create refund, retraction, and adjustment subsequent actions for QA review.
  • Complete daily task independently working remotely using two computer screens.
  • Review treatment pricing posting within internal system through SPARC and Nautilus.
  • Ensure pricing and HPCS are posted correctly per 835 remittance advice.
  • Create refund packet per payer request.
  • Prepare work assignment's using Excel Spreadsheet, Microsoft word, and OneNote.
  • Operate Kronos.
  • Prepared documentation and records for upcoming audits and inspections to ensure company procedures are being applied.
  • Prepared documentation and records for upcoming audits and inspections.
  • Assisted investigation and risk management teams with fraud investigations and risk identification.
  • Build relationships with our consumers.
  • Make 45+ outbound calls payers to reconcile credit balances or potential overpayments.
  • Research 200 accounts and resolve problem, accurately request adjustments on patient accounts.
  • Effectively identify trends and analyze root causes to drive work efficiently within the team.
  • Navigate two computer screens through various payer systems and multiple internal systems to ensure timely and accurate resolution for claims.
  • Stay current on communications relating to healthcare reimbursement and regulatory changes.
  • Develop and maintain positive working relationships with clinical personnel, teammates, and payer representatives.
  • Maintain confidentiality of all company and patient information in accordance with HIPAA regulations and DaVita policies.
  • Understand and adhere to all policies, laws and regulations applicable to this role.
Valley Cities Counseling And Consultation - Contract Revenue Cycle Specialist
City, STATE, 12/2021 - 06/2022
  • Payment posting through 835 display screen.
  • Manually payment posting using Credible software.
  • View and correct claims using Claim.MD.
  • Mange all insurance payments.
  • Search ERA's through Claim.MD.
  • Mange all client’s payments.
  • Batch files using Credible software.
  • Post denials and scanned all copies to MS Teams folder.
  • Verify clients insurance through OneHealthPort, Availty,ProviderOne, Optumcare, and Payspan.
  • Remotely deposit all checks and credit card payments to the business account.
  • Physically deposit all cash payments to the business account by going to the bank.
  • Adjust clients’ accounts to what is on the ERA.
  • Create checks for payer ID/billing purposes..
  • Create checks for payer ID/billing purposes
  • Communicate with peers through email regarding spreadsheets.
  • Communicate with peers through email.
  • Post all capitation payments to the correct accounts.
  • Adjust payments with reason codes and remarks codes.
  • Collect Non-client, donations , and grant payments to the finance department.
  • Communicate with clients who may call to make a payment over phone.
  • Identified and resolved payment issues between patients and providers.
  • Directed and implemented strategic improvement plans to integrate solutions to audit findings and workflow process issues.
  • Monitored closing disclosures to verify documents contained required signatures.
  • Supported Grants Writing Department by pitching in to complete special projects.
  • Wrote or updated standard operating procedures, work instructions or policies.
  • Received, researched and resolved consumer inquiries.
  • Reached out to insurance companies to verify coverage.
  • Generated receivables reports and offered improvement recommendations.
Russell W. Faria - Medical Office Manager
City, STATE, 09/2019 - 06/2021
  • Translate and interpret medical billing codes with strong accuracy to ensure swift payment from insurance agencies
  • Comply with all HIPAA Privacy and security regulations to protect patients' medical records and information using Amazing Charts System
  • Verify all insurance eligibility for Medicaid PCA, commercial insurance, and private pay clients using
  • One
  • Health Port system
  • Review patient diagnosis codes to ensure accuracy and completeness for disability patients
  • Schedule patients in Collaborate MD system and obtain referrals using Clarity System
  • Answer inbound phone calls in a timely and professional manner
  • Greet patients, handle finances, run reports, and oversee independent medical examinations for doctors.
  • Verified eligibility for all departments and completed updates of Managed Care System.
  • Reported enrollment trends and all problems to management at weekly meetings.
  • Completed credentialing applications for providers.
  • Monitored all enrollments to identify any processing problems.
  • Completed other duties as assigned.
  • Make outbound calls to patients, manage inventory, and ensure that supplies are ordered with McKesson, LabCorp, LabQuest.
  • Prepare patients charts for the physician and ensure rooms are prepared for the patients' visits.
  • Provided proper scheduling of patients, ensuring timely and effective allocation of resources and calendars
  • Assessed processes and procedures, complying with OSHA and HIPAA regulations.
  • Created and managed electronic patient records, encompassing data entry and administrative functions related to insurance, billing and accounts receivable.
Baptist South Hospital - Intern Medical Biller
City, STATE, 02/2016 - 12/2017
  • Obtained referrals and pre-authorizations required for procedures
  • Checked eligibility and benefits verification for treatments and hospitalization with EPIC system
  • Reviewed patients' bills for accuracy and obtained any missing information
  • Collected co-payments and current charges
  • Complied daily EOB summary statements.
  • Assisted patients with filling out paperwork for payment arrangements.
  • Corrected all claim errors to facilitate smooth processing
  • Oversaw processing of and preparation of new member enrollments.
  • Completed dis-enrollments as needed.
  • Verified and corrected member eligibility issues at least monthly.
  • Communicated with members and doctors regarding benefits.
  • Utilized state enrollment systems and managed care enrollment systems.
  • Conducted all work in accordance with the confidentiality requirements mandated by HIPAA for member information.
  • Completed newborn enrollments and notified state of deceased member dis-enrollments.
  • Handled summary visits and discharge of patients'.
  • Checked patients out and processed referral's.
  • Verified insurance, accepted payments, and set up payment plans for patients'.

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Resume Overview

School Attended

  • Strayer University
  • Ultimate Medical Academy - Clearwater
  • Jefferson Davis High School

Job Titles Held:

  • Claim Compliance Analyst
  • Contract Revenue Cycle Specialist
  • Medical Office Manager
  • Intern Medical Biller


  • Bachelor of Science
  • Associate of Science Degree
  • High School Diploma

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