Montgomery Street, San Francisco, CA94105(555) 432-1000, resumesample@example.com
Summary
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.
Skills
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
Experience
12/2018 to CurrentReimbursement SpecialistChange Healthcare Inc. | Dover, NH,
Organize monthly reimbursement/ authorizations report.
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.
08/2007 to 03/2018Third Party Liability Specialist, Process Auditor Claims Pend SpecialistHorizon Blue Cross | City, STATE,
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.
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School Attended
University of Notre Dame – Mendoza College of Business
Job Titles Held:
Reimbursement Specialist
Third Party Liability Specialist, Process Auditor Claims Pend Specialist
