stop loss specialist resume example with 15+ years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • Home: (555) 432-1000
  • Cell:
Professional Summary

To obtain a challenging position within an organization that allows me to assist and serve all health matters of any and all aspects where my experience, education, and accomplishments will contribute to the success of the business.

  • Complaint Handling
  • Submitting Files
  • Training Junior Team Members
  • 10-Key Data Entry
  • File Organization
  • 10-Key Typing
  • Remote Video Conferencing
Work History
Stop Loss Specialist, 12/2021 to Current
Edgewood Partners Insurance Center1 Blue Hill Plaza, 12Th Fl,
  • This position is responsible for supporting the coordination and filing of Specs, Advance Funding, and Plan Year End Closeout's
  • Prepare Stop Loss claims and applicable documents to determine Stop Loss filing eligibility applicable to the Excess Loss Policy
  • Files submissions of spec claimants (running reports, gathering necessary documents and email correspondence), processing all submissions within established internal timeframes
  • Coordinate Advanced Funding Requests, with the client and the Stop Loss carrier
  • Maintains database of all specific reimbursement requests
  • Creates initial Specific File for each claimant, files all submissions in our EDOCS platform
  • Coordinates the release of Over Specific, System Hold "on hold" claims
  • Acts as the liaison between the PBM's and internal clients, as it pertains to our Stop Loss claimants
Claims Processor I, 05/2021 to 12/2021
Bluecross Blueshield Of South CarolinaColumbia, SC,
  • Responsible for the accurate and timely processing of claims
  • Research and processses claims accordingly to business regulations, internal standards and processing guidelines
  • Verifies the coding of procedure and diagnosis code
  • Resolves system edits, audits, and claims errors through research and use of approved references and investigative sources
  • Coordinates with internal departments to work edits and deferrals, updating the patient identification other health insurance, provider identification and other files as necessary.
QA Specialist/Auditor, 06/2019 to 05/2021
Bluecross Blueshield Of South CarolinaNashville, TN,
  • Log and track data to be audited
  • Communicate and coordinate with other departments involved in the audit process
  • Audit new and existing plans built by the plan coders
  • Assist with current audit programs in place as well as identify ways to improve results
  • Report audit trends and training requirements to Ancillary Claims Management based on audits
  • Audit data for accuracy as well as workflow compliance
  • Assist with projects as needed by Ancillary Claims Management
Claims Processor II, 11/2018 to 06/2019
LocktonOmaha, NE,
  • Examine and process complex or specialty claims according to business/contract regulations
  • Ensures that claims are being processed in accordance to established quality and production standards
  • Responsible for quality control of High Dollar claims
  • Testing of system updates to identify claims issues
  • Researches and resolves claim edits and deferrals
  • Preforms research on claim problems utilizing policies, procedures, reference materials
  • Reprocessed any claims in regards to information received from the accounting department
  • Completed action requests from Customer Service and other departments
  • Wrote approval/denial letters for Pre-Authorizations
  • Maintain a production level of 1600 processed claims weekly
Account Analyst, 09/2018 to 11/2018
Abnb Federal Credit UnionYork County, VA,
  • Exemplifies extensive knowledge of the hospital revenue cycle with specialization in hospital billing, follow-up, and the account resolution process to include, but not limited to claims submission, acceptance, and adjudication, transaction reviews, adjustment posting, identification of patient responsibility
  • Possesses considerable leadership skills, fostering an atmosphere of trust; seeks diverse views to encourage improvement and innovation
  • Possesses ability to professionally communicate (in all forms) with payer and client resources such as on-site visits, website, e-mail, telephone, customer service departments
  • Identifies systemic issues impending account resolution and recommends solutions for change; suggests performance improvement measures and evaluates their effectiveness against predetermined objectives
  • Desire to develop self and others through coaching; demonstrates awareness of workloads, deadlines, and weak areas needing improvement.
Member Service Representative II, 03/2005 to 08/2014
Neogen CorporationFL, State,
  • Handle telephone calls from providers, subscribers and group leaders in reference to claim payment, benefit verification and errors for multiple accounts
  • Process medical and dental claims for McCrew Care while maintaining production and quality standards
  • Research pre-existing, coordination of benefits, refunds and missed premium issues.
Off-site Coder/Keyer, 12/2003 to 11/2004
Medicare/ Blue Cross Blue ShieldCity, STATE,
  • Keyed hard copy medical UB-92 and HCFA claims.
Customer Service Representative, 05/2002 to 12/2003
Tricare For Life/ Palmetto GBACity, STATE,
  • Answer telephone calls from providers and beneficiaries
  • Reprocessed and adjusted medical claims
  • Worked Deferrals
Skills Microsoft Word, Excel, Power point, Medical terminology, Anatomy and Physiology 1& 2, QicLink System, CPT/ICD: , Expected in 2011 to Central Carolina Technical College - Sumter, SC
-9 coding, CPT/ICD-10 coding, First Health Pricing, Multiplan Pricing, Synchrony
High School Diploma: , Expected in 2001 to Spring Valley High School - , SC

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Resume Overview

School Attended

  • Central Carolina Technical College
  • Spring Valley High School

Job Titles Held:

  • Stop Loss Specialist
  • Claims Processor I
  • QA Specialist/Auditor
  • Claims Processor II
  • Account Analyst
  • Member Service Representative II
  • Off-site Coder/Keyer
  • Customer Service Representative


  • Skills Microsoft Word, Excel, Power point, Medical terminology, Anatomy and Physiology 1& 2, QicLink System, CPT/ICD
  • High School Diploma

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