, , 100 Montgomery St. 10th Floor(555) 432-1000, resumesample@example.com
Summary
Talented healthcare Insurance Specialist ready to leverage in any health-care related environment with extensive knowledge of the healthcare industry and a deep understanding of medical terminology, and insurance. Enthusiastic about growth and developmental skills, insurance account management with excellent planning and problem solving abilities. Offering over 15 years of experience and a willingness to take on any challenge. Organized, driven and adaptable professional with successful history managing high caseloads in fast-paced environments.
Skills
Claim validity determination
Insurance claims management
Medical terminology
Reporting abilities
Documentation skills
Account management expertise
Regulatory compliance understanding
Problem resolution
Reliable and trustworthy
Analytical
Knowledgeable healthcare insurance claims matters
Telephone etiquette
Recordkeeping and data input
Authorizations knowledge
People skills
Friendly, positive attitude
Benefits interpretation
Verbal and written communication
Call center operations
Quality assurance controls
Call control skills
Providing customer support
Quality assurance optimization
Resolving issues
Payment processing
Call documentation skills
Professional telephone voice
Documentation research
Coverage determination
MS Office
Multitasking
Computer skills
Experience
03/2020 to 05/2021Medical Claims RepresentativeConcentra | Cleveland, OH,
Inputted data into the system, maintaining accuracy of provider coding information and reported services.
Based payment or denials of medical claims upon well-established criteria for claims processing.
Documented file notes clearly and concisely.
Sent clinical request and missing information letters to obtain incomplete information.
Reviewed standard contract benefits to process pending claims for benefits.
Reviewed claims for accuracy before re-submitting for billing.
Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
Updated account status records and collection efforts.
Updated company's database daily with any new details regarding collections and activity on delinquent accounts.
Accepted and processed customer payments and applied toward account balances.
Methodically resolved active claims by analyzing possible solutions.
Investigated billing discrepancies and implemented effective solutions to resolve concerns and prevent future problems.
Exceeded customer satisfaction by finding creative solutions to problems.
Analyzed information from interviews, educational, and medical records, consultation with other professionals and diagnostic evaluations to assess clients' abilities, needs and eligibility for services.
Effectively coordinated all communications between patients, billing personnel and insurance carriers.
Provided quick turnaround time when patients called with questions regarding pending or unpaid claims.
06/2017 to 09/2017Medical Clinic Manager Treasure Valley Gastroenterology | City, STATE,
Developed relationships with healthcare providers to sustain strong referral pipeline.
Managed routine operations and clinical projects, including setting targets and performance standards in accordance with company requirements
Completed detailed and efficient assessments of each patient to support development of multidisciplinary treatment plans.
Works in conjunction with the business office to ensure appropriate, accurate and timely financial reimbursement for all services rendered.
Manages, performs and/or assists with patient registration or patient processing, scheduling Medical and Physical Therapy Services, check in/out, and case management per referrals or authorizations.
Communicated with patients with compassion while keeping medical information private.
Assumes all medical records custodian responsibilities in accordance with policy and procedures
05/2013 to 06/2016Clinical Authorization/Medical Claims SpecialistUnited Healthcare | City, STATE,
Inputted data into the system, maintaining accuracy of provider coding information and reported services.
Evaluated pending authorizations to identify and resolve problems blocking auto-adjudication.
Provided assistance to plan participants by explaining benefits information to ensure educated selections.
Reviewed employee enrollments to verify accuracy,
Handled billing related activities focused on medical specialties.
Followed specific security rules and guidelines to protect sensitive data, including patient medical records and payment card information.
Instructed clients on amounts covered under benefits plans in easy-to-understand medical terminology.
Verified that patients had proper insurance coverage prior to any procedures or appointment scheduling.
Examined claims, records and procedures to grant approval of coverage.
Addressed, documented and responded to incoming correspondences to address client queries.
Gathered information to file appeals for denials of services and minimized inaccuracies by maintaining accurate records of approvals.
Answered daily phone calls pre call center requirements.
07/1990 to 05/2012Medical Practice ManagerRobert Nelson M.D.P.A | City, State,
Supervised daily operations of the physician practice, overseeing staff members.
Checked entire office and waiting areas regularly to provide clean and organized surroundings.
Coordinated financial operations, including budgeting, accounting, expenses and financial reporting.
Employed active listening and interpersonal talents to effectively interact with various individuals, including physicians, patients and fellow employees.
Developed and implemented policies and procedures per facility.
Created onboarding program for new staff members, training in customer service and billing procedures.
Complied with OSHA and HIPAA regulations.
Ordered all supplies needed and kept tabs on inventory levels.
Ensure provider enrollment per NPI and provider billing tax ID for billing purposes, assisted in contract negotiating for accuracy with various insurance companies while resolving in-network management issues
Assistant with Prescription, DME, OT and other pre-authorization services.
Education and Training
Expected in 10/2017BBA | Bachelor of Healthcare Administration American InterContinental University, Schaumburg, ILGPA:
Expected in 11/2012Associate of Arts | Business AdministrationAmerican InterContinental University, Schaumburg, ILGPA:
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