Medical Claims Medpay Pip Adjuster resume example with 11+ years of experience
JessicaClaire
Montgomery Street, San Francisco, CA94105609 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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