Medical Claims Processor resume example with 5+ years of experience
JessicaClaire
, , 609 Johnson Ave., 49204, Tulsa, OK100 Montgomery St. 10th Floor
H: (555) 432-1000
C:
resumesample@example.com
Date of Birth:
India:
:
single:
Professional Summary
Effective Medical Claims Processor with strong background building rapport with providers to discuss claim status or claim denials. Driven performer equipped to handle multiple administrative tasks effectively. Exemplary worker with highly investigative skills when processing claims.
Skills
Thorough claims reviews
Computer skills
Health insurance industry knowledge
Knowledgeable in Facets
Insurance claims processing
Scrupulous records management
Medical terms and procedure knowledge
Analytical skills
Account management
Detailed oriented
Written Communication
MS Office
Documentation abilities
Data management
Work History
Medical Claims Processor, 10/2019 - Current Kemper – Boonville, MO,
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.
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.
Responded to correspondence from insurance companies and maintained confidentiality of patient statuses.
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.
BOARD OF DIRECTORS & VP ACADEMIC AFFAIRS & DEAN OF STUDENTS, 07/2013 - 09/2016 Eagle Eye Networks – Austin, TX,
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.
Human Resources Director, 02/2012 - 02/2013 Community Kids Meals – City, STATE,
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.
Education
Master of Business Administration: Public Administration, Expected in 2007 - Columbia Southern University - Orange Beach, AL GPA:
Bachelor of Science: Business Administration, Expected in 2004 - Columbia Southern University - Orange Beach, AL GPA:
Associates: Specialized Business: Business Management, Expected in 2001 - Penn Foster College - Scranton, PA GPA:
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Resume Overview
School Attended
Columbia Southern University
Columbia Southern University
Penn Foster College
Job Titles Held:
Medical Claims Processor
BOARD OF DIRECTORS & VP ACADEMIC AFFAIRS & DEAN OF STUDENTS