A Claims Adjudicator takes care of examining and investigating various insurance claims to determine if the applicant is eligible for a cash settlement or not. A well-drafted Claims Adjudicator Resume indicates the following duties and responsibilities – investigating and negotiating claims filed by the insurance policyholders; processing insurance policyholders’ claims of injury, loss or damage; interviewing claimants, witnesses; paying or negotiating a settlement with the policyholders; working with healthcare industry or health insurance companies; determining the amount of money; and investigating claims filed by the insurance policyholders.
The nature of the job demands the following skills and abilities – extensive knowledge of commercial, Medicaid, Medicare claims and process guidelines; sound knowledge of medical coding billing software; and a strong understanding of different providers’ payment methodologies; and relevant work experience. A Degree is needed to the least.
Objective : Highly motivated individual seeking a challenging Claims Adjudicator position that fully facilitates creativity while utilizing education and experience in achieving desired business objectives.
Skills : Long-Term Disability, Insurance Companies, Social Security, Problem Solving
Description :
Responsible for filing additional claims that are in a pending status until all required information is received.
Responsible for pulling files and paid them when required information is received.
Organized and reviewed medical claims for completeness, accuracy, and took appropriate action to ensure procedures are followed.
Assisted Customer Service Representatives by answering telephone inquiries concerning the status of medical claims, procedures for submitting claims, procedures for submitting appeal letters for then claims are denied for payment.
Assisted Medical Claims Examiners in reviewing approved claims for payment, ensuring information is accurate.
Filled out discrepancy sheets for Adjudicators to correct any misspelled information approved claims.
Assisted the Supervisor and Head of Healthcare Operations on special cases involving medical claims on high-ranking active-duty members to resolve certain issues.
Submitted numerous suggestions to MID (Management Information Department) in the elimination of duplicate payment of claims and to correctly identify Legal cases.
Experience
2-5 Years
Level
Junior
Education
B.S. in HA
Claims Adjudicator Resume
Objective : Analytical Claims Adjudicator with a solid foundation in risk assessment and claims evaluation. Instrumental in developing training programs that improved team performance, leading to a 40% reduction in claim disputes and enhanced accuracy.
Skills : Social Security, Insurance Companies, Medical Records, Adjudicate Claims, Negotiation Skills
Description :
Reviewed claim requests to determine eligibility for processing and escalate to management as necessary.
Made appropriate system entries and verifies accuracy.
Ensures utilization of most up to date processes and procedures to update claims.
Identified process improvements, offered solutions to claim problems, and communicate recommendations to management.
Managed tasks according to company guidelines.
Responded within company standards to inquiries by telephone and written communication.
Worked with colleagues across the organization to research inquiries in a prompt, courteous, and accurate manner.
Experience
2-5 Years
Level
Junior
Education
B.S. Health Admin.
Claims Adjudicator Resume
Headline : As a Claims Adjudicator, responsible to respond to client, member, and/or provider inquiries on claim status, benefit designs, and claim payments working in conjunction with the Customer Service Representative.
Conducted claims adjudication of outside area medical claims using research and application of basic math skills; applied appropriate benefits to patient claims while adhering to HIPAA privacy laws and internal corporate confidentiality rules.
Utilized workbooks and spreadsheets via MS Excel program to facilitate the claims adjudicating process.
Provided supervisors and staff with daily and weekly department reports of volume and production.
Disseminated daily work to the employees on behalf of the supervisor.
Provided limited, targeted training to new hires in specific content areas.
Consistently recognized for individual high productivity and quality through monthly assessments.
Communicated effectively with clients regarding claim statuses, resulting in a 20% increase in customer retention.
Experience
5-7 Years
Level
Executive
Education
B.S. Health Admin.
Claims Adjudicator Resume
Headline : Over 5 years of experience as a Claims Adjudicator, responsible for adjudicating and adjusting medical and/or dental claims against established criteria, and in accordance with specific clients SPDs maintaining goals in accuracy and productivity.
Followed adjudication policies and procedures to make sure proper payment of claims.
Ensured proper guidelines were followed during claim phases.
Reviewed claims to determine if costs were reasonable.
Reviewed claims kit to confirm all items received from beneficiary are in good order prior to issuing payment check applications for completeness and accuracy.
Consulted policy files to verify information reported in a claim.
Examined multiple databases to ensure accuracy of information.
Issued payment to beneficiaries or escheat to appropriate state offices for deceased or unreachable benefic Strong customer/client relationship.
Adhered with continuous training and updates in procedures due to state and contractual changes.
Experience
5-7 Years
Level
Executive
Education
B.S. in HA
Claims Adjudicator Resume
Objective : As Claims Adjudicator responsible for adjudication and processing of medical, dental, and vision claims while interpreting coding and medical terminology in relation to the diagnosis and medical procedures, and payment processing within medical plan benefits.
Skills : Quality Standards, Medicaid, Process Claims, Claims Processing, Data Entry
Description :
Answered and resolved member and provider calls regarding coordination of benefits.
Outreached to Medicare and other insurance companies to update the order of benefits and resolve claim payment.
Researched and reviewed any issues regarding the coordination of benefits.
Processed claims involving any worker's compensation or no-fault cases.
Coordinated benefits between members' claims and other insurance carriers.
Assisted member services with any coordination of benefits questions.
Trained to assist the team with processing of claims.
Experience
2-5 Years
Level
Junior
Education
B.S. Health Admin.
Claims Adjudicator Resume
Objective : Organized, detail-oriented, and conscientious self-starter, able to strategize and prioritize effectively to accomplish multiple tasks and stay calm under pressure.
Skills : Microsoft Office, Health Rules, Customer Service, Employee Training
Description :
Maintained compliance with insurance plan requirements, and with high regard for adhering to goals for quality and claims production rates.
Processed claims in compliance with FIFO guidelines.
Determined any special plan requirements for data entry.
Reviewed claims before entry for completeness and compliance with business requirements.
Entered claims in compliance with customer requirements, but with regard to claims department processes and guidelines.
Maintained weekly-completed claims files.
Maintained compliance with HIPAA guidelines and regulations.
Experience
2-5 Years
Level
Junior
Education
B.S. Health Admin.
Claims Adjudicator Resume
Objective : Dedicated Claims Adjudicator with a focus on customer service and compliance. Enhanced claims processing efficiency by implementing new software solutions, resulting in a 30% decrease in processing delays and increased client satisfaction.
Skills : Process Claims, Data Entry, Medical Evidence, Problem Solving, Communication Skills
Description :
Verified doctor's scripts for Patients entered in care point.
Called and insurance companies and verified active commercial insurance.
Verified reimbursements and tokens payable from insurance companies and patients to dispense medications.
Called local pharmacies to verify if prescriptions were filled will them when getting certain errors reviewing medications.
Assorted orders into proper aux queues for other teams to further work if required.
Reviewed and adjudicated orders at requirements of 11 OPPH while maintaining an error rate at 5%.
Responsible for paying or denying claims based on an internal benefit matrix.
Experience
2-5 Years
Level
Junior
Education
B.S. Health Admin.
Claims Adjudicator Resume
Headline : To obtain a challenging, growth oriented Claims Adjudicator position in a healthcare setting and to utilize related experience, education, and strong professional skills to impact company profitability.
Skills : Customer Service, Medical Evidence, Data Entry, Report Writing, Fraud Detection
Description :
Verified eligibility and covered benefits with insurance company's and long term care facilities.
Checked the accuracy of charges submitted for payment.
Obtained billing authorizations, when required, for all medications being billed to the facility that exceeds the contracted price.
Resolved all claims within a timely manner, this includes claims for medications that were shipped up to 90 days prior.
Validated the information on all medical claims received.
Provided claim status to both providers and insureds.
Reviewed and ensured that there is no missing or incomplete information.
Experience
5-7 Years
Level
Executive
Education
B.S.H.A.
Claims Adjudicator Resume
Summary : As a Claims Adjudicator over 7 years of experience is responsible for processing professional and facility medical claims as well as dental and vision claims for payment or denial.
Skills : Data Entry, Medical Evidence, Process Claims, Empathy, Confidentiality
Description :
Responsible for the analysis and adjustment of Flexible Spending Arrangement (FSA) and Health Reimbursement Arrangement (HRA) claims, employer and participant report preparation, deposit verifications, enrollment activities, and other duties as assigned.
Researched and adjudicated claims for accurate payments.
Produced and inputed claims and declinations.
Completed deposits and process checks and mail them to customers.
Processed various forms and update participant databases.
Interviewed customers, employers, and third parties to gather facts, determined relevant issues related to individual unemployment cases.
Analyzed and applied pertinent laws, rules, and regulations.
Experience
7-10 Years
Level
Management
Education
B.S. Health Admin.
Claims Adjudicator Resume
Summary : As a Claims Adjudicator, over 5 years of experience, proactively managed claims adjudication process as client advocate to reduce client's cost of risk.
Skills : Process Claims, CPT, Medicaid, Social Security, Claims Processing
Description :
Processed claim payments according to provider contracts.
Handled check refunds, reissues, and voids accordingly.
Corrected underpayments. Reported and resolved overpaid accounts.
Replied to provider payment inquiries and provide explanations of payments.
Requested any needed documentation for bill payment.
Interviewed customers, employers, and third parties to gather facts and determine relevant.
Analyzed and applied pertinent law, rules and regulations, and precedents to adjudicate claims.
Issued written determinations to advise interested parties regarding decisions on eligibility for benefits.
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