provider claim resolution specialist resume example with 13+ years of experience

Jessica Claire
Montgomery Street, San Francisco, CA 94105 (555) 432-1000,
Professional Summary

Patient-focused Provider Claims Specialist skilled at claims processing, and office management.

Inpatient and outpatient records coding specialist with working knowledge of ICD-9, ICD-10 and coding . Familiar with commercial and private insurance carriers.

Skilled with technical, clerical and patient support. Strong ability to communicate clearly and effectively to patients and staff.

Skill Highlights

Strong work ethic

Patient-focused care

Strong planning skills

Team player with positive attitude


  • Knowledge of HMOs, Medicare and Medi-Cal
  • Maintains strict confidentiality HIPAA compliance
  • Medical billing software
Professional Experience
08/2014 to 06/2015 Provider Claim Resolution Specialist University Of Kansas Medical Center | Overland Park, KS,
  • Supervisor: Jon Guy, phone number: (913) 240-0227
  • Thoroughly investigated past due invoices and minimized number of unpaid accounts.
  • Recorded and filed patient data and medical records.Demonstrated analytical and problem-solving ability by addressing barriers to receiving and validating accurate HCC information.
  • Strictly followed all federal and state guidelines for release of information.Examined diagnosis codes for accuracy, completeness, specificity and appropriateness according to services rendered.Accurately entered procedure codes, diagnosis codes and patient information into billing software.Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.Appropriately and correctly identified errors and re-filed denied/rejected claims as they were received from the Patient Account Representative.Analyzed and interpreted patient medical and surgical records to determine billable services.Thoroughly reviewed remittance codes from EOBS/AR's.Evaluated the accuracy of provider charges, including dates of service, procedures, level of care, locations, diagnoses, patient identification and provider signature.Submitted refund requests for claims paid in error.Applied payments, adjustments and denials into medical manager system.Performed quality control of the data entry system to verify that claims and payments were posted correctly.Efficiently performed insurance verification and pre-certification and pre-authorization functions.
  • Primarily responsible answering escalated claim adjustment requests.
  • Resolving issues received through transferred provider phone calls, customer service management and miscellaneous special project work.
  • Answers CSR claim inquiries via live transfer and resolves issues real time Thoroughly researches post payment claims and take appropriate action to resolve them within turnaround time requirements and quality standards Liaising between internal departments and customer and data gathering operation.
  • Problem solving while investigating problems of an unusual nature in the area of responsibility.
  • Presents proposed solutions in a clear and concise manner.
  • Assists with special projects as assigned or directed.
  • Knowledge of ICD-9 Diagnostic Codes, CPT Procedure Coding, HCPC Codes using IDX System experience required.
  • Thorough knowledge of medical terminology, enrollment and membership activities, and claims processing procedures/systems.
08/2010 to Present Youth Coordinator Youth Program Developer The Shelter Inc | City, STATE,
  • Supervisor: Laura R.
  • Montgomery, phone number: (XXX) 843-2085 Handled a high volume of emergency placement and new orders.
  • Scheduled appointments and assisted residents with registration and finding information.
  • Coordinated residential intake and handling crisis calls according to procedures.
  • Collaborated with a comprehensive multidisciplinary team of law enforcement, child protective services, medical services, client advocates, prosecution and mental health services from city, county, state, and private agencies.
  • Collaborated with members of the 'Child Protective Team' who plan and execute decisions on placement of children in high risk situations.
  • Assisted residents with filling out assessment forms.
  • Provided on-going mentoring, support, and education to teens and residents.
  • Maintained policy and procedure in regards to customer's Rights and HIPAA.
01/2010 to 07/2012 Research Assistant University Of Kansas | City, STATE,
  • Supervisor: Sarah Pressman (Professor of Health Psychology), phone number: (XXX)764-3000 Accurately and ethically administered Statistical Methods, Data Interpretation, Client referral questions.
  • Accurately and ethically administered and use of various psycho diagnostic instruments including psychometric properties and psychological assessment instruments.
  • Acquired knowledge to evaluate, select, administer, and interpret psychological tests and measures appropriate for the client, the thesis question, and the objectives of the assessment.
  • Coordinated and used SPSS statistical software to analyze data.
  • Applied concepts of hypothesis testing in order to draw statistically valid conclusions.
  • Developed and maintained study databases, codebooks, and procedures for data entry and monitoring regularly and in accordance with all institutional and governmental requirements.
  • Provided regular reports to the Manager and PI regarding study progress and challenges and led the team to address any problems that arise.
02/1999 to 05/2001 Apartment Manger Lakky Apartments | , ,
  • Supervisor's name: Rufus Claire Displayed and explained features of property to client and discusses terms of lease.
  • Planed and organized sales promotion programs and materials, including newspaper advertisements.
  • Interviewed prospective tenants and checked records for qualification Prepared rental contracts including leases.
  • Met with prospective leasers to show property, explain terms of occupancy, and provide information about local area.
  • Directed collection of monthly assessments, rental fees and deposits.
  • Investigated client's financial and credit status to determine eligibility for lease.
Education and Training
Expected in December 2012 to to Bachelor of Arts | Psychology University of Kansas, Lawrence, KS GPA:


Coursework in Healthcare Management


Certified Medical Claim Specialist

Certificate in Electronic Medical Records


Hausa, Yoruba

advanced and fluent


Outstanding judgment, initiative, and attention to detail.

Extensive experience in customer service as well as leading, assisting, and supporting a team.

Excellent interpersonal and organizational skills with persons of diverse populations.

The ability to work independently in a fast-paced environment.

Skilled in SAS, SQL, Proficient in Unix/Linux, Excel, Pivot tables, Microsoft Office, ACCESS or SPSS software.

By clicking Customize This Resume, you agree to our Terms of Use and Privacy Policy

Your data is safe with us

Any information uploaded, such as a resume, or input by the user is owned solely by the user, not LiveCareer. For further information, please visit our Terms of Use.

Resume Overview

School Attended

  • University of Kansas

Job Titles Held:

  • Provider Claim Resolution Specialist
  • Youth Coordinator Youth Program Developer
  • Research Assistant
  • Apartment Manger


  • Bachelor of Arts

By clicking Customize This Resume, you agree to our Terms of Use and Privacy Policy

*As seen in:As seen in: