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Senior Claim Analyst Resume Example

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SENIOR CLAIM ANALYST
Summary

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.



Highlights
  • Medical coding
  • Strong interpersonal and communication skills
  • Self-directed
  • Analytical
  • Team player
  • Critical thinker
Accomplishments

Received a Special Thanks and Recognition Award for creating the Corrected EOB process, auditing guidelines, and training materials.

Experience
Senior Claim Analyst, 11/2013 to Current Kentucky Health Cooperative － Louisville, KY
  • 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.
Commercial Claims, Claims Specialist Claims Administration System CAS
  • 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.
Commercial Claims, Production Lead Claims Administration System CAS
  • 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.
Data Collection and Verification Specialist, 10/2002 to 11/2013 Humana, Inc － Louisville, KY
  • 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].
Education
Bachelor of Science: Information Technology, 2002 GPA: Cum Laude

Information Technology Cum Laude

Presidents Cup Academic Achievement Award
Master of Science: Managing Information Technology, 1 2005 Sullivan University － Louisville, KY GPA: Cum Laude Managing Information Technology Cum Laude
Bachelor of Science: Computer Science, 1 2002 GPA: Cum Laude

Computer Science Cum Laud
Bachelor of Science: Marketing Management, 1 2001 GPA: Cum Laude

Marketing Management Cum Laud
Skills

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

Companies Worked For:

  • Kentucky Health Cooperative
  • Claims Administration System CAS
  • Humana, Inc

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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