Senior Claim Analyst Resume Example
Dynamic insurance professional bringing over ten years in the field of claims with an emphasis on quality.Focused, self-starter, adept, and experienced with leadership duties and enhancing business operating efficiency. Strong analytical, problem solving and collaboration skills in addition to technical proficiency and building customer relationships. Driven individual trained in all aspects of commercial and Medicare claims and contract interpretation. Employs high-level analytical skills in resolving claims to the satisfaction of all involved parties. Analytical thinker and innovative problem solver.
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Received a Special Thanks and Recognition Award for creating the Corrected EOB process, auditing guidelines, and training materials.
- Audit claims for payment and processing accuracy.
- Research and respond timely to claims reprocessing requests, appeals and Department of Insurance complaints.
- Identify and communicate performance and training issues with business processing vendors.
- Assists supervisor in developing policy and procedures, and process work flows.
- Kept up-to-date on changes in Affordable Care Act regulations.
- Reviewed data to verify the validity of claims.
- Adjudicated claims in accordance with government regulations in relationship to contract or group benefit updates.
- Achieved 100% claims processing quality three out of four quarters.
- Served as a subject matter expert and mentor to new associates.
- As a part of the Tech Team, assisted other associates with questions while problem-solving member inquiries.
- Assisted with updating Mentor documentation when documentation was not current.
- Strong technical ability on claims with the ability to resolve issues and determine root cause.
- Lead a team of 15-20 associates and identified training needs for associates.
- Assisted with new associate onboarding in the training environment and out on the floor.
- Managed inventory and aging reports.
- Lead meetings and conference calls for supervisors when needed.
- Performed trial runs with associates to answer questions as they arose to assist associates in solving complex problems.
- Created documentation and led training on Macess and ActionGrams use before these systems were introduced to the team.
- Guided associates in processing claims, working ActionGrams, and using Macess.
- Verify provider demographic information and ensure accuracy of information while coinciding with current auditing guidelines.
- Work with Provider Payment Integrity to update billing addresses for returned checks to ensure providers receive payments.
- Worked on various projects to assist other areas as needed.
- Financial Recovery, Customer Connection Specialist Received a STAR award for improving operational efficiencies by creating the process, training material, conducting training sessions, and establishing auditing guidelines for corrected EOB's.
- Demonstrated excellent listening skills, oral and written communication during calls.
- Exhibited strong analytical and problem solving skills when researching, documenting, and analyzing provider contracts and fee schedules for claims payment accuracy.
- Applied contract interpretation skills to validate financial recoveries with patient accounts.
- Created documentation to determine member responsibility to decrease inventory and maximize production after financial recovery.
- Mentored new associates on procedures and policies of the department to ensure accuracy.
- Medicare Abbreviated Enrollment Forms, Customer Care Specialist Created Abbreviated Enrollment Forms for out-of-service area members before verifying enrollment in the correct plan for their area.
- Surpassed production goal of 4.5 AEF forms per hour.
- Contacted other insurance companies and members for PDP/OI issues, verifying member plans to see if Humana is primary.
- Completed Section A requests to locate phone calls for illegal or improper Medicare Risk HMO sales practices.
- Served as subject matter expert in [Area of expertise] and [Area of expertise].
Information Technology Cum Laude
Presidents Cup Academic Achievement Award
Computer Science Cum Laud
Marketing Management Cum Laud
auditing, billing, oral, contracts, Customer Care, PDP, documentation, Financial, Forms, government, Insurance, interpretation, inventory, listening, meetings, Mentor, policies, problem solving skills, problem-solving, quality, researching, Research, sales, supervisor, phone, written communication
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Resume Overview
School Attended
- Sullivan University
Job Titles Held:
- Senior Claim Analyst
- Commercial Claims, Claims Specialist
- Commercial Claims, Production Lead
- Data Collection and Verification Specialist
Degrees
- Bachelor of Science : Information Technology , 2002
Master of Science : Managing Information Technology , 1 2005
Bachelor of Science : Computer Science , 1 2002
Bachelor of Science : Marketing Management , 1 2001
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