Medical Claims Processor Resume Example

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(555) 432-1000,
, , 100 Montgomery St. 10th Floor
Professional Summary

Proactive Human Resources Manager with strong diplomatic skills, credibility and passion for recruiting, training, and development. Offering 4-year background developing strategic plans, approving budgets and business decisions and representing company to stakeholders. Applicable proven history contributing to the development of HR department goals and objectives.

  • Policy Evaluation
  • Inspections and Reviews
  • Program Oversight
  • Business Administration
  • Financial Management
  • Consulting
  • Employee Development
  • Budgeting
  • Negotiation
  • Written Communication
  • Conflict Resolution
  • Training & Development
Columbia Southern University Orange Beach, AL, Expected in 2007 Master of Business Administration : Public Administration - GPA :
Columbia Southern University Orange Beach, AL, Expected in 2004 Bachelor of Science : Business Administration - GPA :
Penn Foster College Scranton, PA, Expected in 2001 Associates in Specialized Business : Business Management (Finance} - GPA :
Work History
Brink's Incorporated - Medical Claims Processor
San Diego, CA, 10/2019 - Current
  • Followed up on potentially fraudulent claims initiated by claims representatives.
  • Research to respond to inquiries and interprets policy provisions to determine most effective responses.
  • Reviewed provider coding information to report services and verify correctness by navigating multiple computer systems and platforms.
  • Responded to correspondence from insurance companies.
  • Assist Tri-West with special projects building inpatient authorizations to process claim inventory.
  • Processed 150+ CCN, PC3 (1500 & UB04) claims each day using Facets and mailed documentation to clients.
  • Claim adjudication of specialty claims, including, but not limited to, dental, therapy, pharmacy, ambulatory surgery, skilled nursing, duplicate claims, anesthesia, medical assistance, reprocessed claims, in/outpatient, durable medical equipment (DME), & home health care.
  • Maintained knowledge of benefits claims processing, claims principles, medical terminology, & procedures, and HIPAA regulations.
  • Communicated effectively with staff, including members of operations, finance, and clinical departments.
  • Reported policy changes and company conditions affecting customer satisfaction.
  • Evaluated accuracy and quality of data entered into agency management system.
  • Coordinated with contracting department to resolve payer issues.
  • Paid or denied medical claims based upon established claims processing criteria.
  • Reviewed outstanding requests and redirected workloads to complete projects on time.
  • Used administrative guidelines as resource or to answer questions when processing medical claims.
  • Prepared insurance claim forms or related documents and reviewed for completeness.
  • Maintained confidentiality of patient finances, records and health statuses.
Kansas City/Omaha, MO, 07/2013 - 09/2016
  • Reviewed outcomes and metrics to evaluate performance, effectiveness and impact.
  • Defined organizational problems to create and implement correction plans and monitored student enrollment and retention with accurate reporting.
  • Offered expertise on employee and business development plans to enhance implementation and routine oversight.
  • Collaborated with 4 other members to seek involvement in policy decisions, fundraising and visibility of organization.
  • Set, enforced and optimized internal policies to maintain efficiency and responsiveness to demands.
  • Participated in making budgetary decisions by ensuring accurate reporting & auditing of financial and statistical data.
  • Recruited, assigned and prepared schedules for instructors to facilitate classes through curriculum online and in-class academic programs.
  • Coached and counseled management and staff on employee relations, staffing, terminations, complaint resolution, performance management, and accreditations.
  • Maintained progress of students academic track, audits for graduation and chaired graduation committee.
  • Led staff in meetings and follow-through on staff-assigned projects, supervised project management oversight and employed strategic course scheduling strategies.
Community Kids Meals - Human Resources Director
City, STATE, 02/2012 - 02/2013
  • Maintained and monitored over 200 employee records related to terminations, promotions, disciplines payroll administration, leave, I-9's, W-2's, and W-9's.
  • Interpreted policies, procedures, federal laws, organizational standards, and regulations.
  • Implemented and interpreted family la Family Medical Leave Act (FMLA), Short Term Disability (STD), and Long-Term Disability (LTD).
  • Handled on-boarding process for newly hired employees and distributed all paperwork. Coordinated recruitment, interviews, developed job descriptions, and screened applicants. Devised hiring and recruitment policies for 200+ employees.
  • Educated associates on health insurance policies and assisted in evaluating and adjusting associate benefits.
  • Provided training development and supported budget for approximately 200 hourly employees and management staff for workforce optimization.
  • Prepared and reviewed reports pertaining to payroll and performance evaluations.
  • Addressed employee conflicts with appropriate urgency, following all corporate procedures.
  • Created and implemented forward-thinking initiatives to improve employee engagement.
  • Followed programs closely to assess effectiveness and make proactive changes to meet changing demands.
  • Conducted company-wide town hall meetings to convey updates.
  • Created user-friendly employee handbook that was easy to update and maintain.

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Resume Overview

School Attended
  • Columbia Southern University
  • Columbia Southern University
  • Penn Foster College
Job Titles Held:
  • Medical Claims Processor
  • Human Resources Director
  • Master of Business Administration
  • Bachelor of Science
  • Associates in Specialized Business