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Claims Service Specialist Resume Example

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CLAIMS SERVICE SPECIALIST
Professional Summary
Medical Billing Specialist with 3 years experience in a fast-paced, multiple client medical billing company. Researched and denied claims and submitted appeals. Familiar with health billing and collections.
Advanced knowledge of claims processing and pre-authorizations. 
Skills
  • Medical terminology expert
  • ICD-10 (International Classification of Disease Systems)
  • Billing and collection procedures expert
  • Hospital inpatient and outpatient records
  • Inpatient records coding proficiency
  • Outpatient surgery coding specialist
  • HCPCS Coding Guidelines
  • Familiar with commercial and private insurance carriers
  • Insurance and collections procedures
  • DRG and PC grouping
  • Understands insurance benefits
  • Research and data analysis
  • Close attention to detail
  • Adept multi-tasker
  • Office support (phones, faxing, filing)
  • Excellent verbal communication
  • MS Windows proficient
  • Customer service award
  • Skilled trainer
  • Excellent time management skills
  • Microsoft Outlook, Word and Excel
  • MS Office expert
  • Supervisory training
  • Accomplished leader
  • Resource management expertise
  • Knowledge of Medicare statutes and regulations
Work History
Claims Service Specialist, 10/2013 to 06/2014
Allstate Insurance Company – Charlotte, North Carolina
  • Filed claims per NextGen system Discussing coverage's and liability with insured, claimant, and body shops.
  • Also spoke with lienholders and medical providers.
  • Typing and data entry Obtaining police reports to determine liability for claims Reviewing estimates and correspondence faxed, mailed, and emailed in.
  • Issuing payments and scheduling rental reservations for insured and claimants.
  • Precisely completed appropriate claims paperwork, documentation and system entry.

  • Correctly coded and billed medical claims for various hospital and nursing facilities.
  • Verified patients' eligibility and claims status with insurance agencies.
  • Performed qualitative analysis of records to ensure accuracy, internal consistency and correlation of recorded data.
  • Interacted with providers and other medical professionals regarding billing and documentation policies, procedures and regulations.
  • Accurately posted and sent out all medical claims.
  • Submitted electronic/paper claims documentation for timely filing.
Claims Specialist , 10/2011 to 07/2012
Connextions – Charlotte, NC
  • Correctly coded and billed medical claims for various hospital and nursing facilities.
  • Meticulously identified and rectified inconsistencies, deficiencies and discrepancies in medical documentation.
  • Diligently filed and followed up on third party claims.
  • Determined prior authorizations for medication and outpatient procedures.
  • Pre-certified medical and radiology procedures, surgeries and echocardiograms.
  • Researched questions and concerns from providers and provided detailed responses.
  • Reviewed, analyzed and managed coding of diagnostic and treatment procedures contained in outpatient medical records.
  • Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
  • Actively maintained current working knowledge of CPT and ICD-9 coding principles, government regulation, protocols and third party requirements regarding billing.
  • Managed collections claims for unpaid bills against the estates of debtors.
  • Accurately posted and sent out all medical claims.
  • Submitted electronic/paper claims documentation for timely filing.
  • Performed billing and coding procedures for ambulance, emergency room, impatient and outpatient services.
  • Precisely evaluated and verified benefits and eligibility.
  • Responded to correspondence from insurance companies.
  • Identified and resolved patient billing and payment issues.
  • Confidently and adeptly handled claim denials and/or appeals.
  • Evaluated patients' financial status and established appropriate payment plans.
  • Reviewed and resolved claim issues captured in TES/CLAIMS edits and the clearing house.
  • Examined patients' insurance coverage, deductibles, possible insurance carrier payments and remaining balances not covered under their policies when applicable.
  • Updated patient financial information to guarantee accuracy.
Subject Matter Expert , 07/2012 to 10/2013
Connextions – Charlotte, NC

  • Initiated audit process to evaluate thoroughness of documentation and maintenance of facility standards.
  • Created and maintained computerized record management systems to record and process data and generate reports.
  • Supervised 15+ claims specialist and answered work-related questions via chat instant messaging system 
  • Took escalated calls from providers providing excellent customer service and solving all claim related problems. 
  • Manually reprocessed claims for accuracy after being sent back by facilities with questions about denials and non-payment. 
  • Cross-trained and backed up other customer service managers.
  • Solved unresolved customer issues.
  • Assumed ownership over team productivity and managed work flow to meet or exceed quality service goals.
  • Identified individual development needs with appropriate training.
  • Effective liaison between customers and internal departments.
  • Defused volatile customer situations calmly and courteously.
Healthcare Agent,

Education
Associate of Science: Medical Billing and Coding , Current
Central Piedmont Community College - Charlotte, NC
  • Coursework in Business, Accounting and Healthcare Administration
  • Coursework in Healthcare Management
  • Coursework in Healthcare Administration
  • Coursework in Medical Front Office Assisting
High School Diploma: 10 2007
Skills
accounting, benefits, billing, communication skills, customer satisfaction, customer service, customer service training, data entry, focus, insurance, listening, Medical Billing, police, problem resolution, Coding, Read, scheduling, supervisor, Typing, type
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Resume Overview

Companies Worked For:

  • Allstate Insurance Company
  • Connextions

School Attended

  • Central Piedmont Community College

Job Titles Held:

  • Claims Service Specialist
  • Claims Specialist
  • Subject Matter Expert
  • Healthcare Agent

Degrees

  • Associate of Science : Medical Billing and Coding , Current
    High School Diploma : 10 2007

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