Medical Claims Processor resume example with 5+ years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • H: (555) 432-1000
  • C:
  • 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.

  • 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.
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.
Master of Business Administration: Public Administration, Expected in 2007
Columbia Southern University - Orange Beach, AL
Bachelor of Science: Business Administration, Expected in 2004
Columbia Southern University - Orange Beach, AL
Associates: Specialized Business: Business Management, Expected in 2001
Penn Foster College - Scranton, PA

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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

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