Claims Processor resume example with 5+ years of experience

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

Diligent Claims Processor versed in insurance processes and claims procedures. Eager to contribute to team success offering great attention to detail, hard work, excellent organizational skills and time management abilities to successfully handle large volume of claims. Highly accurate and thorough with focus on completing error-free work in line with processing guidelines.

  • Coverage Determination
  • Client Correspondence
  • Data Integrity
  • Reading Comprehension
  • Data Entry Software
  • Work Organizing and Prioritizing
  • Regulatory Compliance Adherence
  • License Verification
  • Compliance Reporting
  • Compliance Monitoring
  • Regulatory and Compliance Understanding
  • Human Resources Support
Work History
07/2019 to Current Claims Processor Long Term Care Partners | Portsmouth, NH,
  • Paid or denied medical claims based upon established claims processing criteria.
  • Used administrative guidelines as resource or to answer questions when processing medical claims.
  • Evaluated accuracy and quality of data entered into agency management system.
  • Verified client information by analyzing existing evidence on file.
  • Generated, posted and attached information to claim files.
  • Maintained confidentiality of patient finances, records and health statuses.
  • Coordinated with contracting department to resolve payer issues.
  • Researched and evaluated accounts for proper adjudication.
  • Performed electronic claims editing and submit claims validation to Veterans Administration Central Business Office for payment processing.
  • The systems used include the VA Fee Basis Claims System (FBCS), VistA, ClaimsXM, Citrix, DataNet and the Claims Processing & Eligibility (CP&E) system.
  • Utilized VA's contracts to evaluate accuracy of payment.
  • Documented claims processing activity into VA systems.
  • Maintained a working knowledge of applicable VA regulations as they relate to proper claims adjudication.
  • Maintained access for all client systems, as assigned.
  • Meet/Exceeds standard productivity and accuracy.
02/2016 to 12/2018 Licensing and Compliance Specialist Fortegra Financial | Farmington Hills, MI,
  • Supported Lead Licensing Specialist by pitching in to complete special projects.
  • Identified deficiencies, discrepancies, and compliance issues with Regional and Division managers in order to determine ineligibility or acceptance status of new and onboarding agents, as well as communicating non-compliant agent status to managers for resolution.
  • Served as coordinator for company licensing process and communicated changes that occur in state regulations to designated personnel.
  • Acted as liaison and corresponded with State insurance departments on licensing, appointments, and continuing education information
  • Compiled, organized, and maintains multiple systems and databases for licenses/appointments information and special reports
  • Developed licensing training manuals used in the licensing, contracting, appointing, and termination, of agents and division managers
  • Served as point of contact for preliminary review of prospective agent candidates for re-contracting validation
  • Reviewed incoming contracting paperwork to ensure all is accurate and complete
  • Completed analysis of background investigation results and coordination of additional information for resolution regarding any complications in background results.
  • Ensured Federal guidelines are met regarding contracting adverse action.
  • Validated producer licensing compliance via State Insurance Department databases prior to hire and appointment setting.
  • Appointed and terminated agents according to State Insurance Department guidelines via email and postage letter.
  • Accessed and maintained multiple systems for the responsibilities necessary for compliance, reporting and payroll updates.
  • Communicated changes affecting production work in a clear, concise, and timely manner via email and postage letter.
09/2014 to 12/2014 Human Resources Specialist West Corporation | City, STATE,
  • Reviewed and screened applicant resumes to ensure completeness and identify qualified candidates for hire or rehire.
  • Oversaw and managed hiring process and assisted human resources.
  • Responsible for performing various day-to-day tasks to assist in the high-volume operational recruiting, testing and hiring process of prospective employment candidates.
  • Met with hiring manager before each class and determined recruitment strategy, and also presented analysis of previous class recruiting efforts;
  • Ensured the company had adequate applicant flow to meet their hiring goals which included identifying/executing supplemental sources of outreach.
Expected in | Elementary Education Wayne State College, Wayne, Nebraska, GPA:
Expected in 05/2015 Bachelor of Science | Business Management University of Phoenix, Omaha, Nebraska, GPA:

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Resume Overview

School Attended

  • Wayne State College
  • University of Phoenix

Job Titles Held:

  • Claims Processor
  • Licensing and Compliance Specialist
  • Human Resources Specialist


  • Bachelor of Science

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