Medical Claim Analyst Resume Example Crawford & Company

MEDICAL CLAIM ANALYST

Professional Summary

Work History

Medical Claim Analyst, 09/2019 to 03/2020Crawford & Company, Crawford , DE

(40 hours).
Assist the nurses in signing the patient valuables in/out of the Fiscal Department.
Assist Payroll with adding insurance group account in system and premium payment.
AVATAR system looking patient name, financial eligibility information, be able to update client data, and access to master client inquiry which allow all episodes of admit dates and discharge dates.
Analyze Invoice which has been received from Anthem BCBS After claim has been paid with claim details to ensure has process based on contract set forward.
Analyze and review all insurance claims submitted to Anthem for payment for accuracy, completeness, and eligibility.
The Medical Claims Analyst will serve as the liaison between NVMHI's Fiscal Department and Anthem and "out of network" providers to solve billing compliances issues.
Used my Investigating skills for the contractual compliance skill set that were needed for my research.
Investigated fraud billing, proper third party billing, and ensure compliance with health care insurance contracts.
Medical Claims Analyst will maintain the patient local care of the petty cash funds and will be I was responsible for deposit of all state all local revenues.
I analyze provider notes, invoicing and investigate medical necessity to detect fraudulent billing, proper third billing and ensure compliance with health insurance contracts.
Reviewed and payroll, processing of invoices for goods and services provided to NVMHI.
Assist the CFO with recording the proper accounting entries for the category of Medical Services expenditures on NVMHI'S financial statements.
Verify any bills submitted directly to NVMHI by insurance providers and confirm the responsible party for payment.
Perform other operational duties in case of an emergency or staff shortage.
Assist the Accounting Technician's with the distribution of funds to patients which allows them access to available cash throughout the week.
Audit Purchase Requisition Form (1) for any corrections with purchase order, accuracy of cost code and object code, verifying signatures of responsible parties and accuracy of vender's statement quotes on product invoices.

Patient Account Representative I, 05/2010 to 07/2019Deaconess Health System, Mount Vernon , IN

(40 hours).
Use independent judgment and initiative to review, analyze and develop solutions for business systems.
Identify, evaluate and resolve complex medical claim issues.
Responsible for processing override requests, resolving customer complaints and provides excellent customer service to recipients and providers.
Knowledgeable of the 837 and 835 files and know the different between the two files.
Review, analyze, and follow-up on various facility/hospital claims that were received for non-payment.
Lead department initiatives for analysis and development of business processes to ensure quality, cost effectiveness, timeliness of customer service, and regulatory requirements and mandates are met.
Develop and prepare financial statements in accordance with existing requirements and company procedures to obtain the desired results.
Audit claims to help reduce operational losses resulting from policyholder fraud or deceit.
Awareness and experience of commercial and governmental insurance payer and clearinghouse portals such as Availity, Navinet, Optum, which including billing guidelines and policy updates.
Reviews requests for reimbursement that the insurer receives and ensures that such requests are valid.
Ensures claims for policyholders are processed accurately and are valid based on the member's benefits and pricing.
Applies generally accepted auditing standards (GAAS) to confirm correctness of claim amounts.
Provide comprehensive functional, regression and integration testing for internal controls.
Track and prioritize defects with project team & business owners and work with developers to resolve any test failures related to financial inconsistencies.
Provide excellent customer service to providers and patients.
Function as a liaison to IS, other department system analysts and vendors.
Support projects to improve processes/controls, partner with project teams to ensure resolution of project/post-project issues and participate on cross-functional projects as a finance representative.
Use GAAP and SAP extensively daily.
Balance patient accounts after insurance company has paid and contract discount has been taken.
Train new hire employees on various types of coverage/line of business Commercial, State, Individual, ASO, and Coordination of Business Medicare Coverage Follow-Up.
Timely identify and obtain information and records from customers, members, providers and/or employer groups to correct/update information, claims and membership records when necessary.
Recognize patterns of inconsistent and/or inaccurate claims filing practices among customers and providers, educate customers and providers.
Three Year Experience on Palmetto GBA- (Medicare) Access eService's - which allow free internet based, provider self-service portal.
Shows the Electronic data interchange (EDI) enrollment of Medicare.
Access give to the Medicare recipient eligibility or claims status.
Access to NcTracks for Medicaid Recipients to be able to research NC tracks database to make a person coming into WakeMed has Medicaid.
We can examine the data provides the online enrollment application and a checklist of Provider Qualifications and Requirements.
Yearly Mandatory assessment training and knowledge of the programs which require for our training and research in rules, regulations, federal and or state laws which include HIPAA legislation that ensure patient privacy.

Financial Recovery Analyst, 11/2001 to 04/2010Blue Cross And Blue Shield Of North Carolina, City , STATE

Acted as a single point of contact for internal and external customer inquiries.
Processed a variety of complex customer financial using the Lawson Software Application.
Assisted the business area in balancing patient financial claims and assisted in auditing of claims payment.
Assisted the testing area in creating test scripts for Lawson testing pertaining to upgrades.
Post Provider payments in regards to refunds and adjustments.
Informed customers about the status of their inquiries.
Analyzed internal and external adjustments to complete prior claim transactions by reflecting the appropriate certificate liability.
Identified and analyzed opportunities for improvements in financial processes, policies and services.
Provided great customer service to 40 clients daily.
Processed credit memos, payments and voucher deducts in Lawson.
Processed correspondence, stop-payments/re-issues and Service First.
Identified trends and suggest ways to achieve optimum accuracy.
Used and navigated Power Manage Healthcare Systems for claims.
Maintained familiarity with BCBSNC policies, claims and membership procedures.
Investigate and reconcile outstanding accounts to determine the cause for the remaining balance.
Made insurance calls to resolve the outstanding account balance and obtain any pertinent information regarding the outstanding claim.
Resubmit corrected claims for appeals to the insurance for processing.
Identify and submit any needed contractual adjustments or other write-offs.
Identify remaining patient responsibility, close out the balance to the patient Systems Utilized:.
AVATAR.
EPIC (Electronic Privacy Information Center ).
SMS (Short Message Service) -Communication infrastructure.
MedAssets-revenue cycle management software.
Windows Microsoft Applications (Excel, Access, Word).
Inter-Plan Programs=IPP out of state claims system application used= BlueSquared-claims apps.
Blue-E-claims electronic exchange, Citrix, PowerMHS-claims.
Magic-holds member's benefits for IPP claims.

Education

Master of Financial Fraud Investigator, 2017

Pfeiffer University

Master of Business Administration, 2010

Shaw University of North Carolina

Master of Healthcare Administration, 2010

Pfeiffer University

Bachelor of Science, Accounting, 1982

Pfeiffer University

Skills

EPIC system- (9 Years)
Claims Processor/Adjustor- (29 years)
Billed Claims
Trained
Trend Analysis
Customer Service- (11 years)
Written/Verbal Communication
Strong Ethics
MedAssets
AVATAR
Availability
PowerMHS
Blue E
BlueSquare
Testing claims
Microsoft Office
Excel
Citrix
Lawson
HIM Department
Denial Claims/ Reprocessing
Managed Care, Medicare, Medicaid and Medicare Supplement
Follow-up Provider/patients
Experience EOB's
EDI
UB04/HCFA 1500
Voucher deducts/credits memos (accounts payable department)
Accounting, Communication Skills, Financial statements, Windows, SMS

Accounts payable, Contracts, Functional, Word, Technician
Administrative, Credit, Funds, Network, Trend
Analyst, Clients, Insurance, Organizational Skills, Upgrades
Analytical Skills, Client, Invoicing, Payroll, Verbal Communication
Microsoft Applications, Excellent customer service, Lawson, Policies, Written
Auditing, Customer Service, Notes, Pricing
Balance, Database, Magic, Processes
Benefits, Electronic data interchange, Medical Terminology, Quality
Billing, EDI, Access, Recording
Business processes, Filing, Excel, Research
Business systems, Finance, Exchange, SAP
Citrix, Financial, Microsoft Office, Scripts

Resume Overview

School Attended

Pfeiffer University
Shaw University of North Carolina

Job Titles Held:

Medical Claim Analyst
Patient Account Representative I
Financial Recovery Analyst

Degrees

Master of Financial Fraud Investigator , 2017
Master of Business Administration , 2010
Master of Healthcare Administration , 2010
Bachelor of Science , Accounting 1982

Medical Claim Analyst Resume Example

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