Medical Claims Examiner Resume Example Healthcare Consultants

MEDICAL CLAIMS EXAMINER

Professional Summary

Driven Healthcare professional with 15 years of hands on experience in a fast-paced healthcare environment. Very motivated and compassionate about my work and job duties. Patient care and wellness is my strong focus which I'm very responsible and accountable for. Highly professional and organized Healthcare Industry with a solid experience in managing and overseeing daily office operations in healthcare as well as coordinating medical and administrative staff to deliver high-quality Healthcare services. Possess excellent communication, leadership, and multi-tasking skills along with the basic knowledge of medical principles, terminology, laws, and ethics

Work History

Healthcare Consultants - Medical Claims ExaminerCumming, GA01/2020 - 03/2020

Collaborated with claims department and industry anti-fraud organizations to resolve claims.
Reviewed new files to determine current status of injury claim and to develop plan of action.
Complete a highly detailed investigation on each claim in a timely manner and fully document the file with pertinent information
Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
Analyzed data to identify underlying principles.
Conducted day-to-day administrative tasks to maintain information files and process paperwork.
Researched claims and incident information to deliver solutions and resolve problems.

BD Medical (reverse Merger, Contract Ended) - Medical Legal Assurance SpecialistCovington, GA06/2019 - 12/2019

Evaluated accuracy and quality of data entered into agency management system.
Perform complaint and quality investigations related to manufacturing, design or clinical use issues.
Review and approve investigations performed by OEM supplier. Managed large volume of medical claims on daily basis.
Ensure consistency to detail in performing and documenting complaint investigations
Evaluates complaints for determining MDR/Vigilance events and document rationale for not filing
MDRs
Determine whether a product malfunction or serious injury reports needs to be filed with the FDA.
Determine whether a 30 day or 5-day MDR report is required.
Maintain the records of all MDRs and documents rationale for not filing MDR's
Create MDR's for review by the Clinical Risk Specialist and also develop inquiry reports to the hospitals on reported claims
Perform final review for closure of complaint files to ensure accuracy, completeness, and attention to detail.
Generates results letters to customers and maintain all required records for the complaint.
Approve decision trees for vigilance reports/international competent authority
Handle competent authority inquires of compliant and other duties as assigned

Healthcare Consultants - Medical Claims AnalystCumming, GA12/2014 - 05/2019

Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations.
Paid or denied medical claims based upon established claims processing criteria.
Followed up on potentially fraudulent claims initiated by claims representatives.
Used administrative guidelines as resource or to answer questions when processing medical claims.
Reviewed provider coding information to report services and verify correctness.
Reported policy changes and company conditions affecting customer satisfaction.
Evaluated accuracy and quality of data entered into agency management system.
Managed large volume of medical claims on daily basis.
Maintained confidentiality of patient finances, records and health statuses.
Processed 70 invoices each a day and mailed documentation to clients.
Communicated effectively with staff, including members of operations, finance and clinical departments.
Communicated verification and authorization status updates with insurance department to facilitate decision-making for patient admissions and insurance coverage.
Resolved conflicts and negotiated mutually beneficial agreements between parties.
Managed quality assurance program, including on-site evaluations, internal audits and customer surveys.

Skills

Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures or government regulations
Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures or government regulations
Strong analytical accomplishments
Excellent written and verbal communication skills
Ability to deal with claimants who are upset
Knowledge of medical terminology and medical billing codes
Attention to detail and thorough note taking

Excellent interpersonal and time management skills
Ability to effectively present information and respond to questions from groups of managers, customers and general public
Valuation knowledge
Insurance policy coverage knowledge
Strong customer service focus
Internet savvy and proficient with Microsoft Word, Outlook, Excel

Education

12/2019Next Level Healthcare TrainingAtlanta, GACertificate: HEDIS/STARR MEASURES

06/2008Columbia Southern UniversityOrange Beach, ALBachelor of Science: Health Administration

12/2014Kennesaw State UniversityKennesaw, GACertificate: Advanced Medical Coding

Resume Overview

Companies Worked For:

Healthcare Consultants
BD Medical (reverse Merger, Contract Ended)

School Attended

Next Level Healthcare Training
Columbia Southern University
Kennesaw State University

Job Titles Held:

Medical Claims Examiner
Medical Legal Assurance Specialist
Medical Claims Analyst

Degrees

Certificate : HEDIS/STARR MEASURES
Bachelor of Science : Health Administration
Certificate : Advanced Medical Coding

Medical Claims Examiner Resume Example

Resume Score: 80%

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