medical claims examiner resume example with 20+ years of experience

Jessica Claire
, , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
Home: (555) 432-1000 - Cell: - - -
Professional Summary

Versatile Medical Claims professional with a career-long record of claims processing, employee training, leadership, regulatory compliance, customer service and meeting company goals utilizing consistent and organized practices. Dedicated, passionate professional with in-depth knowledge of insurance regulations seeking to take on Credentialing Specialist, Compliance Specialist or Benefit/Compensation Specialist role. In my professional role, assisted with overseeing the daily operations of 7 claims adjuster in the claims department, managing a wide variety of tasks and responsibilities, resolve complex claims-related issues, resolve escalated customer issues, collaborated with and maintained open communication with interdepartmental team to ensure effective and efficient workflow to meet tasks/or goals. Ability to work well independently, remotely and in a fast-paced environment. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand. Excellent interpersonal, verbal and written, organizational skills and relationship-building.

  • Critical Thinking, Problem Solving, Decision Making and Leadership
  • Active Listening
  • Time Management
  • Health Insurance Industry Knowledge
  • HIPAA Regulations
  • Medical Terminology, Billing and Coding (ICD-9, ICD-10, CPT and HCPCS)
  • Team Training
  • Microsoft Office: (Word, Outlook, Excel and PowerPoint)
  • Customer Experience
Work History
01/2022 to Current
Medical Claims Examiner Texas Children's Hospital , , Dayton, OH (Remote)
  • Verified eligibility, reviewed and researched incoming medical claims by navigating multiple computer systems and platforms, paid and/or denied medical claims in accordance with Plan policies and procedures, COB and process claims adjustments for additional payments or request for overpayment when necessary.
  • Examined procedures and diagnosis codes for accuracy, completeness, specificity and appropriateness according to services rendered.
  • Read over insurance policies to ascertain levels of coverage and determine whether claims would be paid or denied.
  • Used administrative guidelines as resource or to answer questions when processing medical claims.
  • Requested additional information from doctors, hospital, participants and attorneys when necessary to thoroughly investigate claim.
  • Embrace new systems and processes to increase efficiency.
  • Maintained knowledge of eligibility, benefits, claim processing, claims principles, medical terminology and procedures and HIPAA regulations.
07/2017 to 12/2022
Assistant Claims Adjuster Supervisor Utah Retirement Systems , , Madison Heights, MI
  • Monitored team performance, enforcing compliance with corporate claims processes and procedures.
  • Demonstrate expertise in performing broad array of duties and responsibilities in absence of Supervisor and/or Office Manager to ensure unified departmental workflow.
  • Educate, guide, and assist employees in claims department, creating productive and efficient team.
  • Respond promptly to any questions or concerns submitted by claims adjusters through researching and troubleshooting involved claim.
  • Track and updated provider database on regular basis, including W-9 completions.
  • Cultivated and foster professional working relationships with other operational departments that impact claims process.
  • Investigated, evaluated and adjusted multi-line claims in accordance with standards and laws.
  • Resolved escalated customer issues and boosted retention rates by 55%.
02/2000 to 06/2017
Medical Claims Adjuster Michigan UFCW Unions & Employers Admin, LLC , , Madison Heights, MI
  • Reviewed, completed, and processed variety of medical, dental, and short-time disability claims.
  • Achieved measurable success in sustaining financial and processing accuracy error ratio of more than 99% on consistent basis.
  • Ascertained requirements from patients and/or insurance companies in order to verify claimant benefit eligibility.
  • Requested adjustments for refunds and voids regarding claims that were underpaid.
  • Formulated and delivered work comp and subrogation files, ensuring all information is current and correct.
  • Provided comprehensive training to departmental employees and assisted with other job duties as assigned.
06/1997 to 01/2000
Medical Biller/Front Office Clerk Children's Eye Care, P.C. , , Detroit, MI
  • Greeted visitors and customers upon arrival, offered assistance and answered questions to build rapport and retention.
  • Completed patient check-in processes by verifying insurance and eligibility with insurance companies.
  • Managed over 15 incoming and outgoing calls per day, while recording accurate messages for distribution to office staff.
  • Processed payments and informed individuals of further financial responsibility to facilitate timely payments.
  • Collected payments and applied to patient accounts.
  • Reviewed patient diagnosis codes to verify accuracy and completeness.
  • Performed wide-ranging administrative, financial and service-related functions.
  • Maintained clean reception area to promote positive, professional environment for clients.
Expected in
Bachelor of Science: Health Administration, Pursuing
University of Detroit Mercy - Detroit, MI
Expected in
: Health Care Management
Oakland Community College - Royal Oak, MI,

Transferred to University of Detroit Mercy

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Resume Overview

School Attended

  • University of Detroit Mercy
  • Oakland Community College

Job Titles Held:

  • Medical Claims Examiner
  • Assistant Claims Adjuster Supervisor
  • Medical Claims Adjuster
  • Medical Biller/Front Office Clerk


  • Bachelor of Science

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