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Claims Specialist Resume Example

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CLAIMS SPECIALIST
Professional Summary

To seek a challenging and rewarding career where I can utilize my interpersonal skills, critical thinking skills, and to maximize my growth potential within the healthcare profession. Excellent organizational and administration skills with expertise in dealing with upper management and high-level workloads.

Skills

  • Customer Service, Billing, Conflict Resolution, Professional Liaison, Budgeting, Policy Development, Data Analysis, Managing Change, Strategic /Integrated Planning

  • Team Building Mentorship/ Guidance

  • Effective Communication, Detailed oriented

  • Microsoft Publisher, Microsoft PowerPoint
  • Microsoft Excel, Word Processing
  • Microsoft Office applications
  • Typing 45 wpm/10 key data key
  • Copier, Fax, Scanner
  • Multi-Line Phone System
  • 10 key, Microsoft PowerPoint
  • Administrative, Microsoft Publisher

  • Administrative support

  • Neat

  • Negotiation

  • Benefits

  • Billing,

  • Budget

  • Policies

  • Oral, Problem-solving

  • Conflict Resolution

  • Counseling, Protocols
  • Credit, Quality assurance

  • Research

  • Customer satisfaction, Safety

  • Scheduling

  • Data Analysis

  • Financial, Supervision

  • HR

  • Insurance

  • Team Building, Typing 45 wpm
  • Medical terminology, Word Processing
  • Microsoft Office applications, Written communication skills

  • Coverage assessments

  • Settlement determinations

  • Claims

  • Coverage assessments

  • Accident investigations

  • Reporting skills

  • Documentation abilities

  • Teambuilding

  • Collaboration

  • Multitasking abilities

  • Planning and Coordination

  • Training & Development

  • Detail-oriented

  • Responsible

  • Clerical

  • Relationship-Building

Work History
Claims Specialist, 05/2002 to 09/2012
Company Name – City, State
  • Established and provided benefit and claims adjudication decisions within established authority levels under direct supervision Reviewed and approved medical and miscellaneous hospital invoices on designated claims Negotiated and disputed bills for resolution under direct supervision Summarized all correspondence and medical records in claim log noted as well as file same in the appropriate claim Closed claimant files when appropriate & retrieved closed claim files as requested Provided support to claim staff on client service teams.
  • Implemented improvements in manual and electronic billing procedures.
  • Communicated effectively with staff, including members of operations, finance and clinical departments.
  • Reviewed outstanding requests and redirected workloads to complete projects on time.
  • Maintained confidentiality of patient finances, records and health statuses.
  • Proved successful working within tight deadlines and fast-paced atmosphere.
  • Evaluated and settled complex insurance claims in strict timeframes.
  • Affirmed or denied coverage fairly based on thorough investigations.
Coordinator, 10/2020 to Current
Company Name – City, State
  • Verifies insurance, communicates regularly with carriers and other regulatory agencies for reimbursement purposes.
  • Performs daily and monthly close out procedures for internal controls and cash balancing.
  • Maintains working knowledge of insurance co-pays and deductible, and workman's compensation protocols to ensure accurate and compliant billing information.
  • Promotes customer satisfaction while maintaining a positive, professional manner in both verbal and nonverbal communication.
  • Possesses comprehensive knowledge of corporate policies and procedures as they relate to clinic operations.
  • Answers telephones, takes and directs messages on a timely basis according to the direction and location appropriate to maintain continuous work flow.
  • Maintains an organized and efficient work environment by keeping files and records neat and orderly to promote a smooth work flow and to ensure confidentiality.
  • Coordinates resources necessary to input accurate data, both demographic and medical, collect appropriate fees at time of service and assist patient with financial counseling when appropriate.
  • Carries out all other duties assigned by the Clinic Manager in a timely manner.
  • Completes assigned goals.
  • Managed filing systems for electronic and hard copy documents to keep organized records.
  • Entered and maintained departmental records into company database using EPIC.
  • Maintained master schedule and set up appointments.
  • Maintained accurate, current and compliant financial records by monitoring and addressing variances.
  • Managed office activities by maintaining communication between clients, tracking records and filing all documents.
  • Interacted with customers professionally by phone, email or in-person to provide information and directed to desired staff members.
  • Screened and transferred incoming calls, took down messages and transmitted information and documents to internal personnel as point of contact for office.
  • Established positive working relationships with colleagues, manager and customers through regular communication and effective anticipation of needs.
  • Received and responded to customer requests via letter, email, telephone and in-person approaches.
  • Produced high-quality documents, spreadsheets and presentations for internal and customer-facing needs using MS Office suite.
  • Enhanced collaboration between team members by preparing meeting materials and taking clear notes to distribute to stakeholders.
  • Maintained office supplies inventory by checking stock and ordering new supplies as needed.
  • Delivered clerical support by efficiently handling wide range of routine and special requirements.
  • Reported on daily office activities to help managers stay on top of dynamic conditions and make proactive decisions.
  • Answered and managed incoming and outgoing calls while recording accurate messages for distribution to office staff.
Office Assistant, 08/2013 to Current
Company Name – City, State
  • Adhere to the laws, regulations, and office policies regarding patient confidentiality (HIPPA Compliance Standards) Provide factual information regarding the county or specific medical unit activities and services which may require some interpretation of rules, policies and/or procedures Review financial and insurance status of patient; explain treatment costs and methods of Schedule patient appointments and prepare daily appointment schedule; schedule medical tests and procedures, as assigned Processed payments, verified insurance, ordered tests, completed referrals, and closed patient accounts Provide administrative support to providers and nurses in their care and treatment of patients in the clinic Perform daily administrative tasks to keep the medical office running smoothly Involvement in admission and discharge of patients; providing information and referring patient and family members to an appropriate resource, source and service.
  • Exceptional ability to carry out the instructions verbally, written and diagrammatically Knowledgeable of medical terminology Possess in-depth knowledge of clinic rules and regulations.
  • Welcomed office visitors warmly and alerted staff to arrivals of scheduled appointments.
  • Enhanced collaboration between team members by preparing meeting materials and taking clear notes to distribute to stakeholders.
  • Verified accuracy of business records by consistently updating customer information.
  • Kept physical files and digitized records organized for easy updating and retrieval by authorized team members.
  • Interacted with customers professionally by phone, email or in-person to provide information and directed to desired staff members.
  • Managed office inventory by restocking supplies and placing purchase orders to maintain adequate stock levels.
  • Produced high-quality documents, spreadsheets and presentations for internal and customer-facing needs using MS Office suite.
Billing and Insurance Specialist, 05/2018 to 03/2019
Company Name – City, State
  • Processes insurance claims with individual carriers or agencies to maximize reimbursement.
  • Processes appeals to insurance companies.
  • Prepares, reviews and sends patient statements.
  • Contacts patients by telephone and resubmits claims to third party reimbursers.
  • Responds to written, electronic and telephone inquiries from patients and insurance companies regarding patient accounts.
  • Identifies and resolves patient billing complaints.
  • Refunds patient payments when necessary.
  • Posts insurance payments, returned checks, fees, and patient payments to patient accounts.
  • Reviews each account via computer, reports, and payment sources.
  • Identifies delinquent accounts, aging period, pay sources and reports status of delinquent accounts.
  • Notifies physician of outstanding accounts prior to scheduling patient.
  • Makes recommendations to supervisor and prepares information for collection agency.
  • Contacts patient by telephone, or meets with patient in clinic, evaluates patient financial status and establishes budget payment plans.
  • Receives and records credit card and other payments by telephone.
  • Verifies insurance coverage and benefits.
  • Contacts patient, confirms coverage, and informs patient of their cost.
  • Performs other related work as required.
  • Participates in studies, research projects, or company projects as directed Maintains strictest confidentiality.
  • Treats people with respect and consideration, regardless of their status or position, honoring cultural differences and promoting harassment –free environment.
  • Uses oral and written communication skills to effectively convey ideas in a clear, positive manner.
  • Maintains and follows established PRECISE policies, procedures, and objectives.
  • Observes quality assurance, environmental, safety and security procedures.
  • Conserves organizational resources and is mindful of financial stewardship.
  • Cooperates with medical and administrative staff to ensure compliance with standards and regulations.
  • Responds promptly to customer service needs and requests for service or assistance.
  • Identifies and resolves problems in a timely and professional manner.
  • Adapts to changes in the work environment and manages competing demands.
  • Exhibits sound and accurate judgment and makes timely decisions appropriate to job classification.
  • Implements job responsibilities in a manner that is consistent with GIA's Mission and Code of Ethics.
  • Handled high volume of in-bound calls pertaining to reconciliation of delinquent accounts.
  • Contacted clients with past due accounts to formulate payment plans and discuss restructuring options.
  • Worked effectively with medical payers such as Medicare, Medicaid, commercial insurances to obtain timely and accurate payments.
  • Applied more than 100 payments per week.
  • Managed efficient cash flow reporting, posted cash receipts and analyzed chargebacks, independently addressing and resolving issues.
  • Performed targeted collections on past due accounts aged over 180 days.
  • Generated and submitted invoices based upon established accounts receivable schedules and terms.
  • Identified, researched and resolved billing variances to maintain system accuracy and currency.
Education
St. Joseph High School - City, State
Bachelor of Science: Health Administration
Master of Science: Leadership/Human Resources, 12/2020
Belhaven University - City, State
  • Member of Delta Sigma Theta Sorority, Inc.
No Degree: Vocal Music EducationJackson State University - City, State
Affiliations
Mediator (Delta Sigma Theta Sorority, Inc.) 2015 Mentor (Delta Sigma Theta Sorority, Inc.) 2015
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Resume Overview

School Attended

  • St. Joseph High School
  • Belhaven University
  • Jackson State University

Job Titles Held:

  • Claims Specialist
  • Coordinator
  • Office Assistant
  • Billing and Insurance Specialist

Degrees

  • Bachelor of Science : Health Administration
    Master of Science : Leadership/Human Resources , 12/2020
    No Degree : Vocal Music Education

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