claims subject matter expert resume example

• ·         Responsible for duties in support of all departmental efficiencies as assigned by management

  ·         Scheduled refills per the patients’ plan benefit

  ·         Keyed orders and sent for fulfillment

  ·         Processed RX refills for customers

  ·         Assisted with outbound calling to providers, patient and pharmacies to obtain additional info need to process the RX refill,

  ·         Answered incoming calls

·         Responsible for duties in support of departmental efficiencies which may include: but not limited to performing scheduling, registration, patient pre-admission and admission, reception and discharge functions.

·         Verify medical benefits and eligibility with payers and calculate patient liability collection amounts

·         Completes the whole patient financial clearance process; including educating patients on liability and collection of patient liabilities due.

·         Completes all account documentation and enters the correct activity code when required.

·          Secures insurance authorizations for services and updates account accordingly

·         Performs payment reconciliation & secured payment entry in adherence to financial & cash control policies and procedures

·         Worked as a Claims Examiner for DST Solutions based out of Delaware

·         Responsible for processing Commercial and Medicare Plans.

·         Adjusted backlog claims using the clients claims system for adjudication

·         Knowledgeable of Citrix platform for applications.

·         Utilized Claims Matrix to determine authorization for Delivery, Well baby Newborn, Inpatient Claims, Nursing Home etc.

·         Worked as a Claims Examiner for client Kaiser Permanente Southern California.

·         Responsible for data processing incoming Hospital UB’s for Medicare/ KPSA Plan.

·         Contract interpretation to validate proper payment logic for claim adjudication.

·         Identify billing and coding errors and submit documentation to provider’s if necessary for corrected claims forms to be sent in with the Medicare compliance guidelines.

·         Adjudicate Replacement, Late charge claims etc. accordingly per client’s guidelines for processing.

·         Proficient in Microsoft Word, Excel, Power point, Outlook, Internet Explorer, CMS Pricers, DRG Calculator, ICD-9, CPT, Basic Office Systems and various web applications

·         Worked as a contracted claims expert for Excellus BCBS of NY

·         Responsible for claims processing for the HOME Commercial, Medicare and Medicaid plans

·         Processed claims with the HOST side of the plan updating provider files and credentials to support claims adjustment.

·         Worked any other special projects as assigned by management.

·         Responsible for immediate responses to incoming provider calls regarding claims issues. 

·         Process incoming correspondence from providers on claims issues that need to be resolved for Passport Health (Medicaid) and Passport Advantage.

·         Reprocessing claims as identified through incoming phone calls or submitted by provider relations staff. 

·         Identifying systematic and procedural issues resulting in claims processing errors and initiating action to resolve those issues.

·         Documenting calls, problems, and resolutions for future reference

·         Proficient in Microsoft Word, Excel, Power point, Outlook, Internet Explorer, Facets, IKA Systems, CMS Pricers, DRG Calculator, ICD-9, CPT, Basic Office Systems and web application

·         Worked special projects as assigned by management

·         Answered incoming calls regarding eligibility, claims processing, and billing inquires.

·         Administered employee group benefits for retirees, active, long term disability, and cobra participants

·         Resolved Issues for billing, carrier eligibility, etc.

·         Organized special projects such as web inquiry responses, updating accurate information in our knowledge base customer service tool as assigned by management

·         Team lead/ Initiated training for full-time and temporary associates of ongoing call center and open enrollment.

·         Supported Chicago Medicare , Medicaid and Commercial Markets

·         Received inbound and outbound calls from insured members, clients, brokers, agents and providers

·         Mailed any related correspondence such as enrollment material, forms and brochures to members.

·         Processed medical claims that needed adjustment

·         Knowledgeable of DRG, ICD-9, CPT coding







• Managed customer calls effectively and efficiently in a complex, fast-paced and challenging call center environment.
• Accurately documented, researched and resolved customer service issues.
• Managed high call volume with tact and professionalism.
• Acted professionally and patiently when addressing negative customer feedback.
• Resolved service, pricing and technical problems for customers by asking clear and specific questions.
• Effectively managed a high-volume of inbound and outbound customer calls.

·  Worked as a Claims Examiner for client Kaiser Permanente Southern California.
·   Responsible for data processing incoming Hospital UB’s for Medicare/ KPSA Plan.
 ·   Contract interpretation to validate proper payment logic for claim adjudication.
·  Identify billing and coding errors and submit documentation to provider’s if necessary for corrected claims forms to be sent in with the Medicare compliance guidelines.
·  Adjudicate Replacement Bill Type , Late charge claims etc. accordingly per client’s guidelines for processing. Proficient in Microsoft Word , Excel, Power point, Outlook, Internet Explorer, CMS Pricers, DRG Calculator, ICD-9, CPT, Basic Office Systems and various web applications  
Precisely completed appropriate claims paperwork, documentation and system entry. Thoroughly researched newly identified diagnoses and/or medical procedures to expand skills and knowledge. Resourcefully used various coding books, procedure manuals and on-line encoders.
• Actively maintained current working knowledge of CPT and ICD-9 coding principles, government regulation, protocols and third party requirements regarding billing.