Claims Processor resume example with 20+ years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • Home: (555) 432-1000
  • Cell:

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.

  • Claims Review
  • Payments Posting
  • Data Entry
  • Coverage Determination
  • Transactions Reconciliation
Claims Processor , 03/2022 to Current
Nfi IndustriesBirchrunville, 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 SystemsGreen 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
KemperFort 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 GlobalDallas, 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 StaffingCity, 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
DellCity, 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 HouseCity, 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 LifeCity, 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 GroupCity, 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
- ,
- Fire Safety for CBRF Serving on the eye-to-eye committee at work
MATC: , Expected in 01/2012
- ,
EMT Certificate: , Expected in 01/2012
- ,
MATC: , Expected in 01/1986
- ,
GED: , Expected in
- ,
  • 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


  • 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
  • MATC
  • EMT Certificate
  • MATC
  • GED

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