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Claims Specialist Resume Example

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Jessica Claire
  • , , 100 Montgomery St. 10th Floor
  • H: (555) 432-1000
  • C:
  • resumesample@example.com
  • Date of Birth:
  • India:
  • :
  • single:
Summary

Hardworking Medical Claim Specialist focus in Medicare and Medicaid . Committed to providing optimum service to policyholders. Skilled in review of Medicare payments for correct adjudication. Honest and personable with outstanding administrative abilities.

Previously worked as a reimbursement Specialist in an outpatient Infusion center and a Certified Pharmacy Technician in a 1000+ bed trauma hospital. Have 19 years in Pharmacy experience, which include working with billing and some 340B billing. Currently enrolled in Billing and Coding Classes.

Skills
  • Documentation review
  • Coverage assessments
  • Electronic authorization processing
  • Background in Medicare
  • Database management
  • Insurance terminology
  • Medical terminology
  • Medicaid knowledge
  • Regulatory compliance understanding
  • Documentation skills
Experience
Claims Specialist, 10/2019 to Current
Clyde New York, NY,
  • Researched and reviewed information to determine validity of insurance claims and contacted companies and customers about decisions.
  • Acted as intermediary between insurance companies and customers, including researching and assessing information to determine validity of claims.
  • Oversaw regulatory and strategic initiatives to ensure accuracy of medical claims.
  • Provided quality customer service to all assigned, insured and claimants throughout claims process to deliver timely service to customers.
  • Verified details with policyholders and requested additional information.
  • Supported efficient handling of complex claims and followed up on open, denied or suspended claims to complete required line items.
  • Assessed policy coverage and pulled contracts for review.
  • Knowledge of CPT, HCPCS, ICD-10, and CMS NCCI edits
Reimbursement Specialist, 06/2018 to 10/2019
Envision Healthcare Lake City, FL,
  • Responsible for processing IV infusion orders for reimbursement.
  • Responsible for obtaining eligibility requirements base on individual patient policies with insurance companies.
  • Responsible for Prior Authorizations, Patient responsibility, and patient assistance when needed.
  • Required to follow up on claims that were not paid to obtain payment on denied Prior Authorizations or incorrectly processed claims.
  • Maintained confidentiality and integrity of patient data.
  • Researched rejections, investigating problems to appeal claims.
  • Determined medical necessity, using individual insurance carrier regulations.
  • Identified opportunities for coverage access to address reimbursement barriers.
  • Verified clients' Medical insurance Policies to determine coverage, copays, deductibles, and prior authorizations.
Certified Pharmacy Technician, 07/2017 to 06/2018
Hy-Vee Independence, MO,
  • With Oncology Cancer Center, responsibilities included compounding of Chemotherapy IV’s for daily patients.
  • Ordering of drugs to ensure proper amounts available for patients but not to have a large overstock of medication that would leave us with a high dollar amount of drugs on hand.
  • Responsible for tracking of free drug and order supplies for the Pharmacy.
  • Maintained strict patient confidentiality to adhere to HIPAA regulations and avoid data compromises.
  • Maintained clean and organized pharmacy shelving and work areas.
  • Managed inventories, rotated stock, removed expired or damaged drug products and resolved discrepancies in drug counts.
  • Adhered to regulatory guidelines for workplace safety and customer confidentiality.
  • Adhered to infection control policies and procedures to prevent spread of disease.
  • Received and verified daily incoming drug inventories, reported discrepancies and logged items into inventory system.
Certified Pharmacy Technician, 03/2000 to 06/2017
Hy-Vee Mason City, IA,
  • Accurately fill patient medication requests through dispense que in EPIC Adhere to departmental and hospital policies Accurately compound and admix medication per department and industry standards, including chemotherapy agents.
  • Delivery of medication and supplies to appropriate units in a complete and timely manner.
  • Sterile IV room compounding technician.
  • Responsible for compounding bulk medications.
  • Provide inventory control to maintain proper levels for the hospital in regards to 340B.
  • Maintained strict patient confidentiality to adhere to HIPAA regulations and avoid data compromises.
  • Maintained clean and organized pharmacy shelving and work areas.
  • Managed inventories, rotated stock, removed expired or damaged drug products and resolved discrepancies in drug counts.
Education and Training
: Medical Billing And Coding, Expected in
to
Sinclair Community College - Dayton, Ohio,
GPA:
Bachelor of Science: Technical Management, Care, Expected in 04/2016
to
DeVry University - Dayton, Ohio,
GPA:
Associate of Applied Science: Veterinary Technology, Expected in 06/1992
to
Morehead State University - Morehead, Ky,
GPA:

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  • Target Job

Resume Overview

School Attended
  • Sinclair Community College
  • DeVry University
  • Morehead State University
Job Titles Held:
  • Claims Specialist
  • Reimbursement Specialist
  • Certified Pharmacy Technician
  • Certified Pharmacy Technician
Degrees
  • Some College (No Degree)
  • Bachelor of Science
  • Associate of Applied Science