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Medical Claims Medpay Pip Adjuster resume example with 11+ years of experience

Jessica Claire
  • Montgomery Street, San Francisco, CA 94105 609 Johnson Ave., 49204, Tulsa, OK
  • H: (555) 432-1000
  • C:
  • resumesample@example.com
  • Date of Birth:
  • India:
  • :
  • single:
Professional Summary
Licensed Claims Adjuster experienced in reviewing Medpay/PIP claims, determining coverage and paying claims. Active member of the National Society of Professional Insurance Investigators since 2014. Medical Claims Analysis with 5 years experience providing Benefits Administration for a Third Party Administrator. Advanced knowledge of private insurance processes and codes.
Resume Word
  • TX  Claims Adjuster License
  • Insurance policy coverage knowledge
  • Administrative background
  • Policy investigations
  • Risk management
  • Skilled multi-tasker
  • Highly motivated
  • Advanced oral and written communication skills
  • Organized
  • Customer service-oriented
  • MS Office
  • WLT
  • Fusion
  • Qiclink
  • Word
  • Power Point
  • Accurate and detailed
  • Professional and mature
  • Articulate and well-spoken
  • Flexible
  • Maintains confidentiality
  • Independent worker
  • Works well under pressure
  • Dedicated team player
  • CMS-1500 billing forms
  • Business correspondence
  • Workers' compensation knowledge
  • Dental terminology
  • Behavioral health billing and collections
  • Administrative support specialist
  • Strong interpersonal skills
  • MEDISOFT proficient
Work History
Medical Claims Medpay/PIP Adjuster, 05/2014 - Current
Brink's Incorporated Olyphant, ,
  • Process medical payments for Medpay and Personal Injury Protection claims
  • Confirm insureds facts and update injury loss information
  • Advise insureds of policy benefits, limits and exclusions
  • Send required documentations to all parties involved , insureds, providers and attorney's.
  • Request medical bills, records, treatment plans, wage loss information and employment verification
  • Review medical bills and records for proper treatment and watch for excessive treatment
  • Request Independence Medical Reviews when needed
  • Send eligible claims to vendor for discounts
  • Correspond with attorney's and respond to demand in a timely fashion
  •  Review each state's laws and specifics according to the policy
  • Sit in on round tables to review suspicious and potentially fraudulent claims
  • Keep claim file well documented
  • Contact the insured every 30 days to follow up on injury status.





Medical Claims Processor, 04/2011 - 05/2014
HealthSmart City, ,

  • Point of contact for the members.Validate information on all medical claims
  • Assist members on understand their policy and benefits . Coordinate with Hospitals, Clinics and Medical Claims Teams
  • Handled all incoming phone calls, emails and correspondence
  • Followed up with the Health Review Team for Prior Authorizations
  • Sent out explanation of benefits to members and providers. Requested discounts from vendors
  • Helped members with out of network providers
  • Trained new team mates, sat in on interviews and helped with auditing files
  • Assisted IT with launching a new platform for our groups


Medicare Billing Rep, 02/2011 - 04/2011
St Johns Home Health Medical Supply City, ,
  • Generates revenue by making payment arrangements; collecting accounts; monitoring and pursuing delinquent account
  • Collects delinquent accounts by establishing payment arrangements with patients; monitoring payments; following up with patients when payment lapses 
  • Prepared billing correspondence and maintained database to organize billing information​
  • Interacted with providers and other medical professionals regarding billing and documentation policies, procedures and regulations
  • Reconciled vendor statements and handled payment complaints or discrepancies.
  • Researched and resolved accounts payable discrepancies
  • Reviewed reject Medicare claims ; contacted Medicare for correct HCPCS Codes and modifiers.
  • Reviewed file for write offs

Medical Claims Analysis , 07/2004 - 08/2005
BMI Health Plans City, ,
  • Point of contact for the members
  • Validate information on all medical claims
  • Assist members on understand their policy and benefits
  • Coordinate with Hospitals, Clinics and Medical Claims Teams
  • Handled all incoming phone calls, emails and correspondenceFollowed up with the Health Review Team for Prior Authorizations
  • Sent out explanation of benefits to members and providers
  • Requested discounts from vendors
  • Helped members with out of network providers


Education
High School Diploma: , Expected in 1998
-
Kickapoo - Springfield MO,
GPA:

Associate of Applied Science: Gen EdD HealthCare, Expected in
-
Ozarks Technical Community College - Springfield MO,
GPA:

Medical Insurance Billing and Coding: Insurance and Coding, Expected in 2005
-
Springfield College - Springfield MO,
GPA:
 
  • GPA 4.0
Certifications
    All Lines TX Adjusters License  - 1973434
  • Med/Pay PIP Adjuster focused on exemplary development of consistent curriculum throughout all core subjects and for several different levels. Outstanding communication skills, work ethic and dedication to professional development and continuing education.

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Resume Overview

School Attended

  • Kickapoo
  • Ozarks Technical Community College
  • Springfield College

Job Titles Held:

  • Medical Claims Medpay/PIP Adjuster
  • Medical Claims Processor
  • Medicare Billing Rep
  • Medical Claims Analysis

Degrees

  • High School Diploma
  • Associate of Applied Science
  • Medical Insurance Billing and Coding

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