Claims Examiner III Resume Example

Determines level of reimbursement based on established criteria, provider contract, plan and employer group provisions. Read and comprehend various technical documents such as policies, procedures, standard regulations, technical reports and contracts. Processes all claims eligible or ineligible for payment accurately and conforming to quality, production standards and eligibility, misrepresentation, potential fraud, medical necessity and appropriateness of cares for medical clinic and hospital claims.. Identify, analyze, and evaluate situations or problems to determine and implement appropriate courses of action. Responsible for applying, reviewing, and analyzing information against claims submission by Providers and Hospitals. Researches and resolves unusual high technical or complicated problems from internal and external customers/clients/members disputes and appeals claims. Validates hold codes or suspend status to ensure claims are paid in accordance to policy benefits and providers agreements. Researches and resolves telephone action items routed from CSR

Served as Executive Administrative specialist for the Division Commanding General and staff. Prepared official memorandums for the entire division staff members. Conducted protocol functions during VIP visits and special ceremonial events. Prepared award recommendations, personnel evaluation reports and correspondence. Coordinated travel arrangements and maintained the monthly calendar for the Division Commanding General and his Chief of Staff. Processed Security Clearance requests and Courier card applications. Prepared General staff briefing slides and organization charts.