Claims Processor resume example with 20+ years of experience
JessicaClaire
, , 609 Johnson Ave., 49204, Tulsa, OK100 Montgomery St. 10th Floor
Home: (555) 432-1000
Cell:
resumesample@example.com
Summary
To obtain a position in an office setting with claims processing duties where my varied skills and experience will be utilized. To work with a company that could offer growth and advanced opportunities. Highly-motivated employee with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Skills
Claims Review
Payments Posting
Data Entry
Coverage Determination
Transactions Reconciliation
Experience
Claims Processor , 03/2022 to Current Nfi Industries – Birchrunville, PA,
Processing medical, dental and vision claims
HCFA ,UB's and ADA
Working close with providers on correct billing addresses
Resolved edit errors for several plans, over 300 groups
Process high dollar claims with accuracy
Solved complicated claims
Verifying an inmate is still incarcerated to receive benefits
Eldorado software (Kitty) software
Cigna and Blue Cross, Medicaid and Medicare claims
Work on multiple screens
Work at home full time, private office
Maintained production and quality
Smart Data System (SDS) pulled claims and verified information is correct
Enter pricing on claims from SDS
Data entry, entering paper claims received
Working several reports, termed groups
Cigna and Blue Cross Medicaid and Medicare claims
Completes accurate analysis of claim determination for payment or denial
Monitor claims inventory of assigned accounts and insure turn around and productivity benchmarks are met
Manually price claims based on specific rates
Audit peers work for continued cross training and education
Follow up on provider calls on status, explanation of payment, billing errors and refund requests.
Verified claim data correctness in preparation for processing.
Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
Reviewed history records to determine benefit eligibility for services.
Processed claims for payment or forwarded to appropriate personnel for further investigation
Collaborated with fellow team members to manage large volume of claims.
Checked documentation for appropriate coding, catching errors and making revisions.
Retained strong medical terminology understanding in effort to better comprehend procedures.
Claims Examiner, 06/2015 to 03/2022 Apex Systems – Green Bay, WI,
Validates information on all medical claims, investigates and resolves complex discrepancies
Processes claims in an accurate, efficient and productive manner
Maintains departmental claims per hour and accuracy standards
Makes suggestions to improve the overall processes and procedures of the claims process
Deals with internal/external personnel in an effective professional manner, providing information
Requested and resolving the problem to completion
Processes high dollar claims with complete accuracy
Supports the claims team by participating in special project work as directed by the
Claim Manager
Processing medical claims, adjusting claims and worked on more complicated claims problem solving
Worked on more complicated claims
Resolved edit errors for several different queues
Contacting providers with question relating to charges
Process on three monitors
Validate information on all medical claims and research and resolve discrepancies
Process claims in an accurate, efficient, and productive manner
Maintain departmental claims per hour and accuracy standards
Keep meticulous records of claims and follow up as required and maintain complete confidentiality
Effectively prioritize and organize each workday
Promote and maintain a flexible, cooperative, team environment
Make suggestions to improve the overall processes and procedures of the claims process
Possess analytical, problem solving and math skills
(Math skills include calculating discounts, Percentages, unit values, modifier, and multipliers
Other duties and special projects as assigned
Answer questions from other processors and new employees
Reconsideration of claims and adjust corrected claims from providers
Provider calls, member benefits and claim status.
Reviewed, evaluated and adjusted claims to promote fair and prompt settlement.
Paid and processed claims within designated authority level.
Completed required investigations on referred files within established timeframes.
Evaluated evidence with ultimate goal of creating positive outcomes for client's claims.
Handled and processed variety of claims, including EPO and PPO.
Double-checked and reviewed documentation for denied and accepted insurance claims.
Investigated questionable claims to determine payment authorization.
ED Registration Specialist, 07/2021 to 09/2021 Kwik Trip, Inc. – Osseo, WI,
Arrived new patients in the Emergency room
Arrived all Ambulance and Flight for life with trauma patients
Registered patients in rooms
Knowledge of Epic System, Connex, One Source and Forward Health
Establishes accounts with accurate demographic and financial information to produce a clean claim to the third-party payor
Ensures that all compliance forms are appropriately completed and documented on the patient's account
Efficiently coordinates registrations of all patients
Date data entry skills, Interpersonal skills, and excellent customer service skills
Interacts with patients and/or family members in all situations.
Responded to incoming department phone calls and directed callers to appropriate team members based on need.
Asked various questions from clients to obtain the information necessary for paperwork.
Processed cash, debit and credit card payments for services rendered and printed receipts detailing services.
Welcomed patients to facility and assisted with registration sign-in process.
Adhered to HIPAA guidelines and maintained integrity of hospital policies and procedures.
Carefully checked insurance information for benefits coverage and input pre-authorization documents into system.
Registered patients for outpatient procedures and emergency services.
Contacted insurance carriers to verify coverage, copays and deductible information for patients.
Maintained HIPAA compliance and integrity of hospital policies and procedures.
Greeted visitors and ascertained purpose of visit, issuing needed credentials and directing to appropriate staff or department.
Politely and personably welcomed incoming clients and offered seats prior to beginning registration process.
Scanned ID documents and insurance cards to include in patient charts.
Advised patients of monies required to be paid prior to services.
Provided customer service support and advice on regulations and requirements regarding various registration programs.
Kept processes moving along smoothly so that wait times were minimized.
Protected medical information against unauthorized access, loss or corruption by consistently following security protocols.
Met needs of physicians and other treating team members with timely retrievals of patient medical records.
Developed in-service educational materials.
Claims Adjuster/Analyst/Processor, 07/2014 to 05/2015 Kemper – Fort Lauderdale, FL,
Process medical, cob, vision claims HCFA UB’S
Adjudicate claims that were processed in error
Verify what county and plan the member has to process claim correctly
Aldera system
Adjust Accumulators, deductibles, co-insurance and co-pays
Request overpayments, load overpayments, void checks and reissue, clone claims
Work on two screens to process
Audited processors
Reviewed, evaluated and adjusted claims to promote fair and prompt settlement.
Identified and obtained evidence to ascertain claim value.
Investigated questionable claims to determine payment authorization.
Gathered information from various third parties to determine claim acceptability.
Insurance Ops Sr. Associate, 02/2015 to 04/2015 Ust Global – Dallas, TX,
Processed medical claims for Medicare/cob claims
Resolving error edits
Sending service forms and correcting them
Amysis 6.0 and Macess software
Promoted positive team environment through effective motivational strategies and mediation of issues amongst associates.
Call Center/Customer Service, 12/2013 to 12/2014 Masterson Staffing – City, STATE,
Call Center, Receiving large volume inbound calls
Ordered products for customers
Entered credit card information for payment of product
Problem solving, refunds, replaced products that were damaged or not up to expectations
Dell
Answered incoming calls and provided highest level of professionalism and knowledgeable service to every customer.
Answered, screened and processed high volume of calls daily with call management system and web-based communications.
Resolved customer inquiries, questions and concerns to consistently offer quality service and meet performance benchmarks.
Updated customer accounts, addresses and contact information within call management databases.
Used available resources to provide efficient and accurate solutions for customer service requests.
Delivered fast, friendly and knowledgeable service for routine questions and service complaints.
Asked probing questions to determine service needs and accurately input information into electronic systems.
Managed customer expectations by clarifying needs, identifying options and recommending products and services.
Met or exceeded call speed, accuracy and volume benchmarks on consistent basis.
Maintained strong call control and quickly worked through scripts to address problems.
Consulted with customers regarding needs and addressed concerns.
Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
Engaged in conversation with customers to understand needs, resolve issues and answer product questions.
Collected deposits or payments and arranged for billing.
Strengthened customer retention by offering discount options.
Excelled in exceeding daily credit card application goals.
Claims Adjuster/Data Entry and CNV Associate, 09/2013 to 12/2013 Dell – City, STATE,
Adjudicating Medicaid claims that were processed incorrectly
Examining claims for processing, problem solving
Process Medicaid/Medicare and other secondary insurance claims
Corrected allowed amounts that were incorrect
Diamonds software
Identified and corrected data entry errors to prevent duplication across systems.
Remained focused for lengthy periods to accurately perform work with adequate speed.
Reviewed, corrected or deleted data, verifying customer and account information.
Exceeded quality goals to support team productivity.
Manager Assistant, 10/2012 to 09/2013 Crest House – City, STATE,
Helped with payroll, Billing
Answered phones in a professional manner
Assisted with resident care
Took vitals and passed medication
Build medical charts for residents
Tours for new possible residents
Accounts receivable
Interview new employees for caregiving.
Organized schedules, workflows and shift coverage to meet expected business demands.
Enforced company policies and procedures to strengthen operational standards across departments.
Mentored staff to enhance skills and achieve daily targets, using hands-on and motivational leadership.
Coached team members and delivered constructive feedback to promote better productivity and build confidence.
Delegated tasks to team members based upon skill level and to achieve organizational goals.
Assisted supervisor in evaluating employee performance and cultivating improvement initiatives.
Implemented training processes for newly hired employees and supervised department managers, shift leads and production personnel.
Resolved customer inquiries and complaints requiring management-level escalation.
Remained calm and professional in stressful circumstances and effectively diffused tense situations.
Recruited and trained new employees to meet job requirements.
Assigned work and monitored performance of project personnel.
Interviewed prospective employees and provided input to HR on hiring decisions.
Medical Claims Examiner, 09/2003 to 11/2010 Health Markets/Mega Health And Life – City, STATE,
Processing PPO/HMO/ and Medicare products for multiple states throughout the U.S
Memorizing a variety of different plans and Riders to ensure correct processing of claim
Adjusting claims for resolution
Knowledge for renewal underwriting
Worked closely on backend adjustments for completion per contracts
ICD-9, CPT, HIPPA, HCSA coding and knowledge experience
Reviewed and released payments to medical providers based on various state guidelines
Responsible for adjusting and verification of claims
Experience in processing HCFA’S and UB92’s for various insurance products including
HMO, PPO, POS and Medicare Indemnity
Adjusted claims for resolution
Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
Accurately processed large volume of medical claims every shift.
Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
Tracked differences between plans to correctly determine eligibility and assess claims against benefits and data entry requirements.
Senior Claims Examiner, 02/1998 to 09/2003 Claims Service Resource Group – City, STATE,
Processed medical, dental, and vision claims in a business processing outsource environment
Experienced in processing HCFA’s and UB92’s for various insurance products including; HMO, PPO,POS, Medicare and indemnity
Experienced in processing on multiple software systems, including; FACETS, Macess,
Legacy, Diamonds and Amysis
Responsible to work special projects related to inaccurate claim adjudication
Adjusted claims for resolution utilizing refund and recoup check reports
Consistently adhered to production and quality standards based on standards set forth by client
Trained staff to process on specific projects as requested by management.
Evaluated and investigated assigned claims to recommend workflows, alternate decisions and improvements to future claims handling.
Identified cases with processing deficiencies or requiring higher-level support and coordinated management.
Reviewed, evaluated and adjusted claims to promote fair and prompt settlement.
Paid and processed claims within designated authority level.
Double-checked and reviewed documentation for denied and accepted insurance claims.
Investigated questionable claims to determine payment authorization.
Researched and followed up on denied insurance claims.
Education and Training
American Red Cross CPR Certificate
CBRF/WCTC - First Aid and Procedures to Alleviate Choking
WCTC - Administration and Management of Medications for CBRF
WCTC - Universal/Standard Precautions for CBRF: , Expected in 03/2023 - , GPA: - Fire Safety for CBRF
Serving on the eye-to-eye committee at work
MATC: , Expected in 01/2012 - , GPA:
EMT Certificate: , Expected in 01/2012 - , GPA:
MATC: , Expected in 01/1986 - , GPA:
GED: , Expected in - , GPA:
Accomplishments
Consistently maintained high customer satisfaction ratings.
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Resume Overview
School Attended
Job Titles Held:
Claims Processor
Claims Examiner
ED Registration Specialist
Claims Adjuster/Analyst/Processor
Insurance Ops Sr. Associate
Call Center/Customer Service
Claims Adjuster/Data Entry and CNV Associate
Manager Assistant
Medical Claims Examiner
Senior Claims Examiner
Degrees
American Red Cross CPR Certificate
CBRF/WCTC - First Aid and Procedures to Alleviate Choking
WCTC - Administration and Management of Medications for CBRF
WCTC - Universal/Standard Precautions for CBRF