reimbursement specialist resume example with 14+ years of experience

(555) 432-1000,
Montgomery Street, San Francisco, CA 94105

I am a focused Workman’s Compensation/ TPL Subrogation insurance professional with 10+ years of claims handling experience. I have advanced knowledge of coverage, medical, liability and complex claims handling procedures. I am knowledgeable of state and federal laws with extensive expertise with the Centers for Medicare & Medicaid Services. I possess strong technical writing skills along with exceptional oral communications skills. Good interpersonal, analytical and negotiation skills. Medical coding and billing/ ICD-9/10; HCPCS and CPT experience. Proven Worker's Comp Examiner with exceptional record of achievement in enhancing quality improvement initiatives for billing cycle. Exceptional partner to executive team, improving accounts receivable and assisting with special projects. Dedicated to team success and solving problems with minimal oversight.

  • Accounts Receivable
  • Advertisements
  • AR
  • Benefits
  • Business development
  • Contracts
  • CPT
  • Insurance
  • Legal
  • Litigation
  • Logistics
  • Materials
  • Microsoft products
  • Office
  • Works
  • Operating system
  • Payroll
  • Policies
  • Protocols
  • Research
  • SAP
  • SAS
  • Strategic
  • Tables
  • Training manuals
  • Medical claims
  • Financial calculation
  • Policy evaluation
  • Client service
  • Planning and coordination
  • Process improvement
  • Supervision
  • Operational improvement
  • Project organization
  • Team building
  • Problem resolution
  • MS Office
  • Team management
  • Organization
  • Business operations
Education and Training
University of Notre Dame – Mendoza College of Business Notre Dame, IN Expected in Certificate : - GPA : GPA: 3.5
Change Healthcare Inc. - Reimbursement Specialist
Dover, NH, 12/2018 - Current
  • Organize monthly reimbursement/ authorizations report.
  • Prioritize daily reimbursement/ authorizations schedule.
  • Request, assign and log daily insurance authorizations and denials.
  • Request peer to peer interviews with utilization management.
  • Worked with billing department to reduce contract implementation errors.
  • Educated physicians, staff, patients and stakeholders on service documentation for procedures and coding requirements.
  • Researched rejections, investigating problems to appeal claims.
  • Drafted documents based on payer guidelines and submitted to necessary parties.
  • Determined medical necessity, using individual insurance carrier regulations.
  • Identified opportunities for coverage access to address reimbursement barriers.
  • Maintained confidentiality and integrity of patient data.
  • Coded patient care records to provide accurate information for billing.
Horizon Blue Cross - Third Party Liability Specialist, Process Auditor Claims Pend Specialist
City, STATE, 08/2007 - 03/2018
  • Managed and processed high dollar claims with payouts over $50,000.00.
  • Identified and led recovery of over $330K in overpayments.
  • Trained team of 10 in the use of the NASCO operating system.
  • Handled severe complex injury files and coverage issues.
  • Works effectively with subrogation team and makes proper recommendations for disposition of No-Fault and Workman’s Compensation claims.
  • Supports SIU involvement.
  • Research/adjust claims (i.e., Coordination of Benefits, no-fault, claim policy, authorizations, and referrals) in accordance with plan contract provisions and all other governing policies and procedures.
  • Research and resolve Accounts Receivable (AR) issues to include the disposition of cash receipts in Universal Payment System (UPS).
  • Exceptional knowledge of OSHA; ERISA; Medicare and Medicaid; COBRA; ESRD and state and federal guidelines.
  • Advised team members, managers and directors on claim processing procedures.
  • Experience analyzing medical evidence, benefit and/or legal evidence to identify and recognize required actions for claim development.
  • Advanced knowledge of Microsoft products; including SAS and pivot tables.
  • COB, Medicare and adjusted claims processing.
  • Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level.
  • Prepares necessary state fillings within statutory limits.
  • Manages the litigation process; ensures timely and cost-effective claims resolution.
  • Coordinates vendor referrals for additional investigation and/or litigation management.
  • Uses appropriate cost containment techniques including strategic vendor partnerships to recover the cost of claims for the company.
  • HEDIS; SAP; SAS; Navinet; Careplanner; Burgess; NASCO.
  • ICD9/10 CPT and HCPC and CPT codes.
  • Prepared budgets, developed reports and coordinated with management to identify risks.
  • Researched and implemented best practices to improve audit results.
  • Performed information system audits to manage internal controls and assess risks.
  • Attended and participated in industry events.
  • Monitored new trends and technologies related to audit areas to implement modifications in processes and procedures.
  • Designed internal control policies to improve audit scores.
  • Complied with Sarbanes-Oxley Act and GAAP principles to maintain complete transparency.
  • Performed audits of operational and financial areas to check compliance.
  • Devised and initiated corrective strategies to improve compliance.
  • Presented audit results to management teams, delivering information in non-technical terms for easy understanding.
  • Collaborated with external partners to complete audits.
  • Wrote reports, authored papers and organized supporting documentation.
  • Updated and managed accounts payable databases, employing access controls to protect data.
  • Updated and managed accounts payable databases, employing access controls to protect data.
  • Analyzed audit areas' design and operational effectiveness.
Tom Ridge For Governor - Minority Coalition Manager
City, STATE, 12/1991 - 12/1993
  • Trained and develop over 150 volunteers and 20 staff members during the campaign.
  • Negotiated contracts.
  • Created targeted advertisements and made media buys.
  • Maintained office payroll, petty cash, schedules and training manuals.
Activities and Honors
  • Ordained and licensed Minister.
  • Peer mediation 50-hour Stephen’s Ministry training to provide counsel and peer to peer support to individuals dealing with tragic life events.
  • Life Application Seminar: provide Bible based life skills training to inmates incarcerated with the NJ Department of Corrections.
  • Grant writing seminars: provide free grant writing classes and support to non-profits.

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Resume Overview

School Attended

  • University of Notre Dame – Mendoza College of Business

Job Titles Held:

  • Reimbursement Specialist
  • Third Party Liability Specialist, Process Auditor Claims Pend Specialist
  • Minority Coalition Manager


  • Certificate

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