Claims Analyst Resume Samples

Description :

1. Acted as a liaison to other departments, including claims, Provider relations, customer service and enrollment.
2. Identified areas in the system that are not handling claims appropriately and recommending solutions to the appropriate party.
3. Helped to determine under-and over-payments in the claims and contracting areas.
4. Served as a subject-matter-expert on billing, enrollment and claims.
5. Identified loading errors and took the appropriate corrective measures.
6. Audited provider contracts to make sure that they met Medicaid guidelines to ensure that provider contracts are set up correctly in the different systems.
7. Worked closely with Provider Relations to enhance Provider relationships through claims analysis and education to the providers on correct billing techniques.
8. Analyzed contracts and contract language in regards to correct rates and fee schedules.

Experience

7-10 Years

Level

Management

Education

Diploma

Description :

1. Review and analyze supplemental mortgage insurance claims to determine whether the claims should be paid, denied or returned for more information.
2. Successfully completed a background check and obtained HUD security clearance in order to access HUD's computer systems to retrieve claim data.
3. Review and analyze supplemental mortgage insurance claims submitted by financial institutions from HUD to determine the completeness, accuracy and compliance of the claim with HUD's regulations.
4. Based on review of the claim and supporting documentation, either pay, deny or return the claim for additional documentation.
5. Contact financial institutional staff to obtain missing documentation or clarification of claims submission.
6. Batched completed claims for submission to HUD.

Experience

5-7 Years

Level

Consultant

Education

Nursing

Description :

1. Audit patient treatment records for accuracy and completion.
2. Determine level of reimbursement by evaluating established criteria.
3. Audit the accuracy of all processed claims based on a comprehensive knowledge of benefit package.
4. Perform regular check runs to meet processing time standards.
5. Responsible for the accurate processing of all categories of specialty, ancillary, PCP and ER/UC claims through review and daily audit.
6. Develop and provide examination training based on findings from audit process.
7. Maintain a quality assurance program to support the total performance management.
8. Provides second review of bills on which providers questions the appropriateness of payments authorized Assist and advise claims examiner concerning the monitoring of claimants medical treatments.

Experience

2-5 Years

Level

Executive

Education

Medical Billing

Description :

1. Provide written and verbal customer service to policyholders, agents, and brokers.
2. Responses must be timely, service oriented and consistent with service standards.
3. Contact clients to obtain missing information or data to ensure complete and accurate customer needs.
4. Reviews, analyzes and processes claims/policies related to events to determine extent of company's liability and entitlement.
5. Understanding of the application of benefit contracts, pricing, processing, policies, procedures, government regulations, coordination of benefits, & healthcare terminology.
6. Knowledge of claims and products, including the grievance and/or re-consideration process.
7. Issues member refunds to correct account overages, identifies if refund requests need to be requested from provider or member.
8. Research prescription and medical claim accumulations and correct if needed.

Experience

7-10 Years

Level

Management

Education

Diploma

Description :

1. Performed the full range of medical claims analyst assignments including reviewing, analyzing, investigating and processing a high volume of medical claims in accordance with accounting principles and legal guidelines; Comprehensive understanding of the laws and guidelines concerning medical claims, and fully compliant with HIPPA regulations.
2. Adept at analyzing complicated insurance data and financial reports, working in conjunction with clients, plan participants, health care providers, insurance representatives and internal and external associates; experienced with healthcare claims management using the Electronic Medical Records (EMR) software, and direct billing to Medicaid and Medicare.
3. Knowledge of accounting principles, regulations, procedures, and systems.
4. Verifying and updated information on submitted claims, resolving discrepancies; Negotiating payment to all parties;
5. Monitoring payment progress Full compliancy with HIPPA and Health facility policies and regulations.
6. Comprehensive understanding of the laws and guidelines concerning medical claims.
7. Analyzed complicated insurance data, working in conjunction with insurance representatives and monitoring payment progress.
8. Specialized in data entry, filling out insurance paperwork and the software that is specific to the industry.

Experience

2-5 Years

Level

Executive

Education

BA In Accounting

Description :

1. Review and analyze claims for Long Term Care insurance policy holders.
2. Process new claims and disseminates the appropriate reimbursement(s).
3. Write written correspondence for approval and denial letter(s).
4. Train new employee(s) on policies and procedures.
5. Ensure all claims payments are issued in a timely and accurate manner for state variances.
6. Assist in identifying exposures to the company and report to senior-level management on pending claims and litigation that may have an adverse impact on the corporate goals.
7. Communicate effectively with internal and external policyholders and providers.
8. Assisted with IBM DataCap to help oversee with indexing of all incoming mail for the claims department.

Experience

2-5 Years

Level

Executive

Education

Associates In Accounting

Description :

1. Perform data entry into an electronic claiming system.
2. Review all medical/surgical billings for reasonable and necessary charges.
3. Verify the validity of medical claims submitted by the physician's office, hospitals and patients.
4. Access all medical/surgical claims to ensure they adhere to current healthcare industry regulations and policies; and are on compliance with insurance procedures and allotted benefit coverage.
5. Analyze medical claims received to provide accurate claims payments to providers or third parties in accordance to all Plan provisions.
6. Helped to reduce medical claim backlog to become current in accordance to industry standards.
7. Review claims processing procedures and update as needed.

Experience

2-5 Years

Level

Executive

Education

High School Diploma

Description :

1. Responsible for developing a solid understanding of assigned client's process in order to strategically review and analyze their A/R functions.
2. Conduct regular audits of representative claim work for accuracy and quality.
3. Provide direction to client leads on claim audit corrections and resolution.
4. Prepare and analyze reports of audit review and performance issues with a focus on identifying trends, instituting continuous quality improvement initiatives, and identifying and providing on-going training opportunities for representatives - by utilizing Business Intelligence.
5. Provide 2nd tier review on advanced and escalated claims issues to a satisfactory resolution.
6. Log all client issues encountered in internal tracking system, including enhancement requests, bugs, errors and inquiries.
7. Make management aware of any client issues or problems.
8. Participate in continuing education of applicable software and hardware.

Experience

5-7 Years

Level

Consultant

Education

Diploma

Description :

1. Provide claims research utilizing Fiscal Intermediary Shared System (FISS) to process Medicare claims to determine what was denied and the reason for claims denial.
2. Communicate claims research findings and return cases to nurse after obtaining denial information in FISS.
3. Perform case tracking, productivity and quality statistics.
4. Utilize computers for spreadsheet, word processing database management, and other applications.
5. Prepare reports memos, letters of completed claims and other documents in accordance with company procedures.
6. Electronically sort and compile text and numerical data, retrieving, updating and merging documents as required.
7. Perform data entry activities, verifying data with source documents, validating information and checking to prevent errors.
8. Compute and verify totals on report forms, requisitions, or bills using adding machine or calculator.

Experience

5-7 Years

Level

Executive

Education

Diploma

Description :

1. Responsible for answering live calls, voicemails, emails and written correspondence from customers regarding quality and liability claims of filters manufactured by UCI-FRAM.
2. Communicate with customers in regards to progress/tracking current and past claims.
3. Evaluate and disposition claims in the lab.
4. Extensive customer service and quality assurance among customers and within corporation.
5. Track/Process all customer claims/complaints using Microsoft Excel, Access and Oracle, Sharepoint, SAP and Master Document systems.
6. Produce weekly claims analysis reports and track trends.
7. Utilize knowledge of automotive technology, as well as technology in other product applications on a daily basis.
8. Process requests for payment of claims through accounting as well as Third Party Adjustors.

Experience

10+ Years

Level

Senior

Education

Marketing And Management

Description :

1. Reviews and analyzes claims and loss expense reserves established by insurance carriers.
2. Acts as liaison between the insurance carriers and insurance broker to maintain loss expense reserves.
3. Processes new claims and disseminates the claims to the appropriate insurance carrier.
4. Acts as liaison between corporate and field offices to facilitate the gathering of information that will facilitate proper response to claim losses and legal documents.
5. Oversees and performs administrative support tasks for the Director of Risk Management.
6. Takes and transcribes dictation Composes and prepares confidential correspondence reports and other complex documents.

Experience

2-5 Years

Level

Executive

Education

MA

Description :

1. Basic claims adjudication and review Investigate and apply contract benefits.
2. Identify and report any irregularities or trends in claims processing.
3. Log all pertinent information into claim notes during the adjudication and review Contribute to the efficiency of department by being flexible and cross-trained on other functions.
4. Maintain and promote a productive and positive work environment that is free from harassing or disruptive activity or behavior.
5. Responsible for quality and continuous improvement within the job scope.
6. Follow all guidelines as outlined in the most current version of the PH Tech Personnel Handbook.
7. Read and follow all required policies and procedures.

Experience

2-5 Years

Level

Executive

Education

Associates Of Applied Science

Description :

1. Review and analyze claims loss and expense due to defective material caused by the manufacturer.
2. Act as an Liaison between Flooring Services and Vendors to maintain loss expense that are reflective of the company's exposure.
3. Process new claims and disseminates the claims to the appropriate Vendor.
4. Act as an Liaison between Builders/Homeowners and Field Contractors to facilitate the gathering of information that will allow the response to claim losses and legal documents.
5. Act as the liaison to Sales Representatives, Vendor Representatives and Inspectors investigating any incidents/issues that may result in a win/loss.
6. Organize movers, cleaners, lodging and handles Per Diems in the result of a replacement due to defective material.
7. Takes and transcribes dictation and composes and prepares correspondence, reports and other complex documents.
8. Catalogs and records job files for storage.

Experience

2-5 Years

Level

Executive

Education

Sociology

Description :

1. Investigate and adjust Proof of Claims (POC)/Notice of Determination (NOD) submitted to the company.
2. Allocated Loss Adjustment Expense (ALAE) Project.
3. Investigate and adjust invoices/bills submitted to the company.
4. Set/Update reserves as needed for construction defect, property damage, liability and auto property damage claims.
5. Access multiple data systems to matching POCs to coverage and existing claims; setting up new claims; determining location of existing claims; entering data into POC Systems.
6. Make recommendations regarding coverage of claims.
7. Handle complex and high exposure liability claims.
8. Participate in special projects as assigned by Claims Manager and/or Department Head.

Experience

2-5 Years

Level

Executive

Education

Insurance Society

Description :

1. Managed a weekly desk load of 100-130 disability claims while maintaining consistent excellence in audits.
2. Surpassed the individual claim limit and assigned a desk load of an average of 300 claims per week.
3. Was part of a pilot team for senior analysts and managed a desk called complex claim desk. I was the go to person in my team for claims and complex claims.
4. Provided exclusive and exemplary customer service to major clients Handled international claims from specific policies through successful bilingual communications.
5. Address and transition complex situations across multiple claim management software and operating systems.
6. Multitask and managed multiple tasks at the same time.
7. Assisted team members in the handling and interpretation of complex policy language and special handling.

Experience

0-2 Years

Level

Entry Level

Education

B.S In Marketing