complex claims specialist resume example with 20+ years of experience

Jessica Claire
Montgomery Street, San Claireco, CA 94105 609 Johnson Ave., 49204, Tulsa, OK
Home: (555) 432-1000 - Cell: - - : - -
Pursue a challenging position within the given industry where my excellent schooling, expertise, assertiveness and dedication can be utilized. To be part of a dynamic motivated team in an environment that encourages professional growth in my profession.

* Extensive customer service expertise * Exercise exceptional judgment and patient confidentiality * Handle difficult patients with a positive attitude * Excellent written and oral communication skills * Willing and able to handle a wide variety of tasks * Very organized, detail oriented, and efficient * Able to take on new challenges, Flexible * Highly motivated and goal orientated, dedicated and loyal * CPT Coding, ICD-9 * Insurance verification * Medical Terminology Software Skills: Outlook, Word, Windows, Excel, PowerPoint, FoxPro & Medisoft, Insurance authorization, Surgery scheduling, EMR - (Spring charts)

Medical Assistant Degree - Pioneer Pacific College, Wilsonville, OR - Honors graduate / Alpha Beta Kapa
06/2006 to Current
Complex Claims Specialist Hiscox Lisbon, ME,
  • Responsibilities
  • As a Complex Claims Specialist, I act as a liaison between the client, medical provider(s), employer, and patient working towards assuring quality medical care is delivered in a timely manner.
  • Meeting Performance Benchmarks on assigned claims.
  • Understanding and appropriate application of Contract Requirements and MCO Policies and Procedures.
  • Compliance with patient confidentiality policy, company policy, and state law
  • Coaching and mentoring team members
  • Directing the claim and being the primary point person responsible for planning case management activities to move the claim forward toward closure and return to work.
  • Assuming an active role in identifying red flags that prevent claim to progress expeditiously toward claim closure or return to regular work.
  • Making independent decisions and communicating with the adjuster on plans of action
  • Communicating medical management information to insurer timely
  • Appropriate and timely use of Physician Reviewers
  • Ability to shape PR responses in line with case management plan to move claim forward
  • Keeping current with the diary in order to give excellent customer service, showing the customer that enrolling the claim has allowed them to move the claim to closure and regular work faster than would have been possible if the claim were not enrolled.
  • Keeping pre-cert turnaround time within an average 24 business hour turnaround time.
  • Closing claims timely.
  • Notifying the supervisor of backlog, with a solution for corrective action prior to identification on a management report.
  • Proactively notifying the supervisor or escalating unresolved issues per the Open Door policy before service issues are raised to the next level at the client's office.
  • Attending trainings and utilizing available resources that further education in medical, legal, and strategy techniques relevant to workers compensation case management.
  • Brushing up on topics, reviewing reference manual information, reviewing medical information topics presented or taped, etc.
  • Appropriate use of Medical resources - MDA, ODG, PT Guidelines and internal protocols
  • Actively monitor for ways to increase customer service to the customers so service exceeds their expectations
  • Sharing opportunities for increasing customer service with team members in case procedural changes are necessary.
03/2005 to 06/2006
GENERAL SURGEON Peace Health Cottage Grove, OR,
Medical Assistant (first p/t - now full) Responsibilities Patient Rooming; Vitals; Charting & History; Assistance with Exams to include minor surgery; (needle core, excision/punch biopsies, excision and drainage, incision and drainage); Wound care; Autoclaving; Removal of JP drains, staples, sutures; Exam/surgical room stocking; Surgical preparation as needed; Surgery scheduling; Obtain verification of insurance for surgery; PASS scheduling, following anesthesia guidelines; Schedule diagnostic imaging, labs, nuclear medicine thru various sites to include: Providence St. Vincent's, Tuality, Epic Imaging, Body Imaging, Meridan Park, Tillamook, Portland Clinic and others; Request diagnostic imaging films from various sites as well as pickup or have sent depending on where facility is located; Phone triage, Call in new prescriptions as well as refills; Call patients with labs, diagnostics and path results as indicated per doctor, documenting call in each appropriate chart; Assist receptionist with appt scheduling when necessary; Confirm patient appointments; If needed, assist with verification of patient insurance prior to upcoming appt.; Inventory of surgical supplies; Scan patient charts into Spring charts; Fax pts records as needed per request of various doctors; Make sure that clean linens (gowns, sheets and pillowcases) are on hand at all times; Handle pickup of biohazard material as well as Iron Mountain for confidential material.; Keep Dr. Hoeksema's schedule updated.
02/2005 to 09/2005
Assist instructors Cancer Care Northwest Coeur D Alene, ID,
with course curriculum; grade exams; quizzes and work papers; fax; copy; Monitor injections and phlebotomy; Assist with vitals; Manage student files. LEGACY CLINIC (Family Practice & Internal Medicine) Tualatin, OR 01/05 thru 02//05 Medical Assistant Externship Responsibilities Patient Rooming; Vitals; Charting & History; Assistance with Exams to include minor surgery; Injections; Hematocrit; Urinalysis; Cultures; CLIA Testing; EKGs; Pulse-Ox/Nebulizer Usage; Glucose Level Testing; Strep Testing; Crash Cart Maintenance; Autoclaving; Ear Lavages; Exam/surgical room stocking; Ekg & Surgical preparation as needed.
02/2005 to 04/2005
Medical Assistant Cintas Corporation Chicago, IL,
(p/t - several days/wk) Responsibilities Assisted Dr. Gabel with hair restoration surgery to include: prep of patients, injection of anesthetic, assist with removal of donor site, assist with implantation of new hair to scalp; Set-up surgical room and cutting room on surgery days; Cut hair graphs; Surgical/cutting room stocking; Safety technique utilization; Autoclaving; Ordering of supplies; Clean-up post surgical procedure.
01/1979 to 01/1989
Executive Administrative Assistant CENTURYTEL City, STATE,
Responsibilities Full range of analytical tasks performed to include, but not limited to: Monthly Final Trunk Blockage reporting; polled access line reporting data; monitored Directory Assistance and Non-recurring revenues; extracted data for Federal Incentive Plan; projected extended area service calling scopes; maintained DSL database core model. Responsibilities Developed and coordinated detailed travel itinerary for Director of External Affairs and provided all necessary information related to schedule business appointments; Managed, organized and distributed the full range of incoming correspondence, making decisions and action required on most items, releasing Director for more important activities; Coordinated meetings and appointments, which frequently included major corporate clients; Maintained detailed records and prepared all expense reports for Director, thereby releasing him for more pressed activities; Handled multiple phone lines, screening and dispersing calls to the proper executives; Maintained all records/files relating to every aspect of Director's responsibilities for the company and outside affiliations; Revised a form to track business expenses more efficiently; expediting preparation of a final summary and reimbursement; Gathered and organized budgetary information; Monitored and reported monthly variances; Prepared and edited reports; Drafted correspondence.
Expected in to to
Medical Assistant:
Pioneer Pacific College - Wilsonville, OR
Medical Assistant Degree - Pioneer Pacific College, Wilsonville, OR - Honors graduate / Alpha Beta Kapa
Expected in to to
: Communications
Gonzaga University - Spokane, WA
Communications, Gonzaga University, Spokane, WA
Expected in to to
Clark College - Vancouver, WA
Computer, Clark College, Vancouver, WA
Medical Terminology Medisoft Medical Assistant CPR BLS EKG
Access, Database, Dsl, Receptionist, Administrative Assistant, Aspect, Clients, Correspondence, Executive Administrative, Executive Administrative Assistant, Multiple Phone Lines, Case Management, Claims, Closing, Coaching, Compensation, Corrective Action, Customer Service, Increase, Liaison, Medical Management, Mentoring, Pr, Progress, Public Relations, Retail Sales, Workers Compensation, Medical Assistant, Autoclaving, Stocking, Documenting, Drainage, Epic, Imaging, Inventory, Nuclear Medicine, Scheduling, Wound Care, Clia, Ear, Ekg, Maintenance, Medical/clinical, Phlebotomist, Phlebotomy, Testing, Billing, Coding, Cpr, Cpt, Cpt Coding, Detail Oriented, Emr, Excel, Excellent Written, Foxpro, Icd, Icd Cpt, Icd-9, Medical Invoicing, Medical Terminology, Medisoft, Office Medical, Outlook, Powerpoint, Very Organized, Word, Ordering

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Resume Overview

School Attended

  • Pioneer Pacific College
  • Gonzaga University
  • Clark College

Job Titles Held:

  • Complex Claims Specialist
  • Assist instructors
  • Medical Assistant
  • Executive Administrative Assistant


  • Medical Assistant

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