LiveCareer-Resume

medicaid eligibility specialist resume example with 10+ years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • H: (555) 432-1000
  • C:
  • resumesample@example.com
  • Date of Birth:
  • India:
  • :
  • single:
  • :
Summary

Demonstrative Eligibility Specialist proudly offering over 10 years' experience assisting others with enrollment and program services. Polished professional known for interactions that are fair, compassionate and respectful. Promoting issue resolution expertise in fast-paced environments.

Skills
  • Advocacy and Counseling
  • Recordkeeping and data input
  • Telephone etiquette
  • Applicant support and service
  • Knowledgeable in Epic
  • Team building
  • Customer service
  • Conflict Resolution
  • Computer Skills
  • Organization
Experience
Claims Analyst, 01/2015 - Current
State Of Georgia Douglas, GA,
  • Reviewed coverage determinations, investigated and evaluated claims and negotiated settlements
  • Investigated claim and settlement deals and reviewed coverage determinations.
  • Investigated and analyzed requirements to improve timeliness of reports to customers.
  • Adhered to company and insurance client's guidelines in claims processes, estimate writing and claim closures.
  • Determined insurance coverage levels and restrictions by thoroughly examining claims forms and associated records.
  • Communicated with reinsurance brokers to obtain claim information for processing.
  • Uploaded documentation and reports to corporate database system using Epic to facilitate smooth claims processing.
  • Analyzed first reports of loss and underlying file material to determine if claim was suspect.
  • Checked into questionable claims, interviewing agents and claimants to resolve errors and omissions.
  • Investigated potentially fraudulent claims with focus on thoroughness, quality and cost control.
  • Reduced loss ratios through fair and prompt processing of claims.
  • Conducted secondary evaluations of original investigations documentation and reports to facilitate smooth resolutions.
  • Created master spreadsheet to record procedures, denials and approvals.
  • Worked with underwriting on loss reserves and risk assessment and coordinated field reviews.
Appeals and Denials Coordinator , 02/2013 - 01/2015
Yale-New Haven Health North Haven, CT,
  • Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions.
  • Acted as intermediary between insurance companies and customers by researching and assessing information to determine claim validity.
  • Checked documentation for appropriate coding, catching errors and making revisions.
  • Retained strong medical terminology understanding in effort to better comprehend procedures.
  • Created master spreadsheet to record procedures, denials and approvals.
  • Signed payment approvals accepted claims.
  • Collaborated closely with other team members to resolve large volume of claims on daily basis.
  • Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.
  • Modified, updated and processed existing policies and claims to reflect changes in beneficiary, amount of coverage and type of insurance.
  • Processed claims for payment or forwarded to appropriate personnel for further investigation
Release of Information Specialist, 04/2011 - 01/2013
Harris Health System Katy, TX,

Effectively processes medical records for Northside Hospital to ensure quality and timely care of the patients which will in turn, apply the correct reimbursement

• Delivered protected health information and patient requests within strict deadlines Maintained expert attention to detail within a fast-paced environment and handled all denials Proficiently navigated through electronic filing system while obtaining pertinent information needed for their files Ensured release of information was in compliance with Health Insurance Portability and Accountability Act Submitted recommendations towards process improvement in order to enhance overall workflow and efficiencies Maintains confidentiality, security and standards of ethics with all Company and medical records information including request for law offices requiring subpoenas

• Ensures that files are adequately prepared in a timely manner to meet strict Social Security Disability deadlines

• Exercises sound judgment and critical thinking skills in the execution of job duties and knows when to ask for guidance and/or share information with supervisor and/or Manager

• Maintains working knowledge of the current state laws regarding fee structure, and HIPAA regulations as well as facility policies and procedures in regards to release of information

• Attends and participates in required educational training sessions and staff meetings as scheduled and assigned Knowledge of Healthcare Effective Data & Information Set (HEDIS) reporting, healthcare industry experience and healthcare data

Education and Training
Bachelor of Business: , Expected in
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STRAYER UNIVERSITY - ,
GPA:
Status -

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Resume Overview

School Attended

  • STRAYER UNIVERSITY

Job Titles Held:

  • Claims Analyst
  • Appeals and Denials Coordinator
  • Release of Information Specialist

Degrees

  • Bachelor of Business

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