claims reconsideration recovery specialist resume example with 9+ years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • H: (555) 432-1000
  • C:
  • Date of Birth:
  • India:
  • :
  • single:
  • :
Professional Summary

Knowledgeable and dedicated customer service professional with extensive experience in Client Service industry. Solid team player with outgoing, positive demeanor and proven skills in establishing rapport with clients. Motivated to maintain customer satisfaction and contribute to company success. Specialize in quality, speed and process optimization. Articulate, energetic and results-oriented with exemplary passion for developing relationships, cultivating partnerships and growing businesses.

  • Customer service
  • Data entry
  • Database
  • Documentation and reporting
  • Team Leader
  • Listening
  • Excel spreadsheets
  • Microsoft Office
  • Policies
  • Quality
  • Verbal and written communication
  • Professional Telephone Voice
  • Teamwork
Work History
Claims Reconsideration & Recovery Specialist, 04/2012 - 10/2020
Pgim Global Short Duration High Yield Fund, Inc. NE, State,
  • Proficient knowledge of Managed Care with a focus in Medicare, Medicaid and Chip.
  • Provider management experience.
  • 9 years of CPT and HCPCS coding experience.
  • Excellent organizational and interpersonal skills that promote a strong work ethic and positive work environment.
  • Computer Skills: Microsoft Office, SQL, MHS, Health Edge, Health Rules Payor, iHealth, IPNS (Argus), Macess, CCMS, OnContact, Allscripts, and Mumms Medical Software.
  • Investigated claims data via SQL and adhoc queries to ensure accurate processing, and initiate timely overpayment recovery and reconciliation.
  • Strengthened provider relationships by delivering superior service via mailed in appeals and inbound calls to create a positive customer experience.
  • Facilitated and managed a process improvement team to further enhance the internal and external customer experience.
  • Served as a liaison for a Medicare Financial Consultant
  • Process routine claim adjustments resulting from external inquiries, other internal department referrals and claim quality review efforts in a timely manner according to established guidelines.
  • For reconsideration requests submitted on excel spreadsheets, document outcome of appeal in designated fields by timelines assigned by Team Leader or Supervisor.
  • Analyze claims adjudicated in error, making recommendation to Supervisor or Team Leader for process improvements.
  • Meet production and quality expectations for the department.
  • Receive a score of 90% or better on monthly quality audits measuring courtesy, listening, communication, knowledge and documentation.
  • Assist the unit in meeting and maintaining performance standards, such as 10% or less call abandon rate, 30 seconds or less average answer delay and 80% or higher service level.
  • Exercised remarkable customer service to both internal and external inquires.
  • Managed large data projects, including workflow scheduling, data entry and accuracy verification.
Claim Examiner, 04/2013 - 04/2014
Bluecross Blueshield Of South Carolina Jacksonville, FL,
  • Accurately adjudicated Medicare , Medicaid and CHIP claims in compliance with data entry rules, policies and contractual agreements.
  • Reviewed suspended claims on a daily basis, assuring that all appropriate documentation is complete before adjudication.
  • Accurately completed service forms for suspended claim s and routes to designated areas for resolution.
  • Reviewed audits results on a weekly basis, correcting errors in the claims processing system.
  • Maintained minimum performance standards as specified by departmental policies, such as claim production and accuracy.
  • Reviewed audit results on a weekly basis, correcting errors in the claims processing system within designated time frames.
Document Control Clerk, 04/2012 - 04/2013
  • Responsible for maintaining and updating accurate document files and medical claims to key into computer database and processed.
  • Demonstrates proper procedures for confidential information.
  • Archives documents for same storage and disposal after entered in computer.
  • Knowledge of Macess, MHS and Microsoft Office.
  • Maintained minimum performance standards as specified by departmental policies, such as keying claim production and accuracy.
  • Ability to stay above average in key strokes per hour on a month basis.
  • XXX0 KPH and above..
CSSR/Personal Banker, 10/2010 - 02/2012
Wells Fargo City, STATE,
  • Created innovative financial solutions to meet customer needs and provide competitive edge.
  • Expanded client base by promoting new financial products.
  • Continually boosted branch production and revenue by consistently meeting all monthly and quarterly sales goals.
  • Provided primary customer support to internal and external customers in fast-paced environment.
  • Assisted customers with setting up or closing accounts, completing loan applications and signing up for new services.
  • Promoted products or services to each customer to consistently achieve sales targets.
  • Balanced teller drawers and ATM cash.
B.A: Business Administration, Expected in
Pierce College - Philadelphia, PA
Status -
High School Diploma: , Expected in
West Philadelphia Catholic HS - Philadelphia, PA
Status -

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Resume Overview

School Attended

  • Pierce College
  • West Philadelphia Catholic HS

Job Titles Held:

  • Claims Reconsideration & Recovery Specialist
  • Claim Examiner
  • Document Control Clerk
  • CSSR/Personal Banker


  • B.A
  • High School Diploma

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