A Claims Auditor will take charge of claims auditing tasks such as analyzing payments, procedures, and guidelines of benefits. The primary tasks that can be seen highlighted on the Claims Auditor Resume are – interpreting detailed paid claims report and eligibility report; determining eligible types of services, monitoring claim financials, performing routine follow-ups, reviewing claims liabilities, adjudicating claims accurately as per the complex contractual obligations, confirming correctness of claim amounts, and ensuring that the policy is still in force when the claim is made.
Job skills expected on resumes include these – strong analytical and problem-solving skills, the ability to exercise good judgment in solving complex cases, a strong sense of individual responsibility with high ethical values. Data management ability with computing skills are well required. Knowledge of GAAS is crucial. Employers want education such as a college degree in auditing, finance or accounting. Major supervisory duties, however, necessitate a Master’s degree.
Headline : Accomplished Claims Auditor with 7 years of experience in optimizing claims processes and ensuring accuracy in payments. Proven ability to analyze complex claim data and enhance operational efficiency. Committed to maintaining high standards of compliance and accuracy in audits, contributing to organizational success.
Skills : Claims Processing, Audit Compliance, Data Analysis, Attention To Detail
Description :
Assisted customers in navigating claims processes, addressing inquiries and issues effectively.
Requested necessary documentation from clients to ensure claims processing accuracy.
Processed claims for both national and international packages, ensuring compliance with company policies.
Conducted routine audits of provider claims to ascertain payment accuracy for Medicare and Commercial plans.
Collaborated with team members to optimize workflows and enhance service delivery.
Utilized Excel and Access for comprehensive data analysis and claims reporting.
Maintained meticulous records of audits and findings to support regulatory compliance.
Experience
5-7 Years
Level
Executive
Education
B.S. in BA
Claims Auditor Resume
Objective : Dynamic Claims Auditor with 5 years of experience specializing in claims analysis and compliance verification. Adept at identifying discrepancies and enhancing claims processing efficiency. Driven to uphold the highest standards of accuracy and integrity in audits, fostering trust and reliability within the organization.
Executed comprehensive audits of claims, ensuring adherence to company policies and regulatory standards.
Maintained a high accuracy rate while processing and auditing claims, optimizing workflow efficiency.
Utilized various software applications such as Facets and Emdeon for accurate claims review.
Processed commercial, Medicare, and Medicaid claims, ensuring compliance with all guidelines.
Served as a key resource for auditing medical insurance claims for AFLAC’s Puerto Rico clients.
Consistently surpassed management-set quotas, contributing to team goals and objectives.
Provided translation services to facilitate effective communication of claims information.
Experience
2-5 Years
Level
Junior
Education
B.S.B.A.
Claims Auditor Resume
Summary : Seasoned Claims Auditor with a decade of experience specializing in claims analysis, compliance, and audit processes. Expert in identifying discrepancies and implementing effective solutions to enhance operational accuracy and efficiency. Passionate about upholding regulatory standards and delivering results that support organizational integrity and success.
Conduct thorough audits of claims to ensure compliance with policies and regulations.
Collected and audited claim submissions for payment accuracy and compliance.
Produced detailed Explanations of Benefits and Claims Settlement payments.
Managed comprehensive claim research, processing, and payments.
Conducted audits of post-payment physician and facility claims to ensure accuracy and compliance with regulations.
Analyzed potential fraud scenarios across multiple client accounts for Medicare, Medicaid, and commercial products.
Review and analyze claims data for accuracy and completeness.
Experience
10+ Years
Level
Senior
Education
B.S. Accounting
Claims Auditor Resume
Summary : With a decade of experience as a Claims Auditor, I excel in evaluating complex claims data and ensuring compliance with industry standards. My expertise lies in identifying discrepancies, optimizing claims processes, and enhancing operational efficiencies. I am dedicated to delivering precise audit results that drive organizational integrity and support financial accuracy.
Conducted comprehensive audits of workers' compensation claims, ensuring accuracy and timely payments.
Investigated UB-92 claims discrepancies and resolved issues within the Power Track system.
Collaborated with the Sedgwick coordinator to retrieve essential claimant information.
Followed up with commercial insurance companies to verify the status of filed claims.
Engaged with the Juris Coordinator to re-queue claims when necessary.
Managed hard copy claims that required manual processing due to scanning issues.
Provided peer training for new employees, fostering a culture of accuracy in claims processing.
Experience
7-10 Years
Level
Management
Education
B.S. Accounting
Claims Auditor Resume
Summary : Results-oriented Claims Auditor with 10 years of extensive experience in analyzing claims data and ensuring compliance with regulatory standards. Proven expertise in identifying and resolving discrepancies to enhance claims processing efficiency. Dedicated to delivering accurate audit results that contribute to organizational integrity and operational success.
Administered the claims process by matching claims to prior approvals, auditing, and verifying data entries for accuracy.
Maintained and updated customer profiles in the SalesForce database to facilitate efficient claims handling.
Ensured proper documentation was submitted to confirm amounts requested for payment based on invoices.
Generated and verified all client reports, ensuring accuracy in customer statements and detail reports.
Conducted audits of claims batches, managing high-volume workflows effectively.
Translated and processed invoices to identify currency conversions and apply international tax rates.
Utilized Microsoft Office skills, particularly in Excel, to analyze claims data and generate reports.
Experience
7-10 Years
Level
Management
Education
B.S. Accounting
Claims Auditor Resume
Headline : Results-driven Claims Auditor with 7 years of expertise in auditing claims for accuracy and compliance. Skilled in analyzing complex data sets to identify discrepancies and enhance operational workflows. Committed to delivering meticulous audit results that bolster organizational integrity and efficiency.
Skills : Data Analysis Tools, Documentation Skills, Problem Solving, Regulatory Compliance
Description :
Developed and implemented analysis and reporting mechanisms to enhance claims auditing processes.
Created effective communication methods for reporting trends and provided training to team members.
Delivered precise audit results, clearly explaining any discrepancies identified.
Collaborated with management to tailor audit reports for claims and customer service units.
Facilitated feedback sessions to improve the quality of audit work.
Produced monthly summary reports that encapsulated audit data for management review.
Assisted in drafting written procedures for identified areas of improvement.
Experience
5-7 Years
Level
Executive
Education
B.S. in BA
Claims Auditor Resume
Headline : Dedicated Claims Auditor with 7 years of specialized experience in claims review and compliance assessments. Proficient in identifying discrepancies and enhancing audit processes to ensure accurate claim resolutions. Passionate about driving operational excellence and maintaining regulatory adherence to support organizational integrity.
Reviewed Medicare claims for accuracy and compliance with regulatory standards.
Responded to inquiries from the compliance team regarding eligibility, claims, and provider issues.
Audited various claim types including DRG, Inpatient, and Mental Health to ensure correct processing.
Developed and conducted training for staff on claims processing and compliance requirements.
Facilitated remote training sessions for international teams on claims submission processes.
Monitored member eligibility status using the MARX system to ensure accurate claims processing.
Collaborated with stakeholders to enhance claims audit workflows and improve operational efficiency.
Experience
5-7 Years
Level
Executive
Education
B.S.B.A.
Asst. Claims Auditor Resume
Objective : Proficient Claims Auditor with 5 years of experience in analyzing and auditing claims for compliance and accuracy. Skilled in identifying discrepancies and implementing effective corrective actions to enhance operational workflows. Committed to delivering precise audit results that uphold regulatory standards and drive organizational efficiency.
Reviewed client systems to ensure accurate claims payments in accordance with coordination of benefits.
Enhanced the accounting quality control system, preparing it for key audits.
Communicated effectively with Medicare, patients, and employers while auditing and cataloging claims.
Developed comprehensive training manuals for onboarding new clients.
Monitor claims trends and provide insights for risk management.
Managed claims processing for multiple accounts, improving turnaround times.
Handled inquiries regarding benefits and claims status, ensuring timely resolution.
Experience
2-5 Years
Level
Junior
Education
B.S.B.A.
Associate Claims Auditor Resume
Objective : Strategic Claims Auditor with 5 years of experience in evaluating claims accuracy and ensuring compliance with industry regulations. Expertise in analyzing complex data to identify discrepancies and optimize claims processing. Passionate about enhancing operational integrity and delivering precise audit outcomes that support organizational goals.
Skills : Process Improvement, Insurance Knowledge, Critical Thinking, Report Writing, Data Entry
Description :
Executed thorough claims examination procedures, ensuring accuracy in data management.
Conducted extensive audits on health insurance and Medicaid claims, producing detailed audit reports.
Analyzed and determined outcomes for medical and pharmaceutical claims based on compliance standards.
Ensured audits adhered to contract provisions, effectively minimizing processing errors.
Maintained high data integrity standards across internal and external sources.
Investigated medical claims for potential fraud, documenting findings in compliance with regulations.
Leveraged strong analytical skills to interpret complex data sets and drive audit accuracy.
Experience
2-5 Years
Level
Junior
Education
B.S. Accounting
Asst. Claims Auditor Resume
Summary : Results-focused Claims Auditor with 10 years of extensive experience in auditing complex claims and ensuring regulatory compliance. Proficient in analyzing data to identify discrepancies and implementing corrective actions that enhance operational efficiency. I am dedicated to delivering precise and actionable audit insights that support organizational integrity and drive financial accuracy.
Served as the main liaison between insurance companies and service providers, ensuring seamless communication.
Negotiated and validated vehicle repair estimates, facilitating timely payments to auto body shops.
Developed performance scorecards for body shops, enhancing partnerships and service quality.
Reported analytics to stakeholders, focusing on critical metrics that drive customer satisfaction.
Delivered tailored solutions compatible with clients' systems, optimizing claims processing.
Processed an average of 100 claims daily, significantly exceeding industry benchmarks.
Implemented auditing procedures that resulted in substantial cost savings for the organization.
Experience
10+ Years
Level
Senior
Education
B.S. Accounting
Claims Auditor Resume
Objective : Ambitious Claims Auditor with 2 years of experience in evaluating claims for accuracy and compliance. Adept at identifying discrepancies and enhancing audit processes to ensure proper claim resolutions. My analytical skills and attention to detail contribute to efficient claims processing and organizational integrity.
Skills : Confidentiality, Root Cause Analysis, Claims Management, Financial Analysis, Attention To Compliance
Description :
Communicated with Production Manager to resolve errors effectively.
Audited member liability denials ensuring claim quality and accuracy.
Ensured accurate payment rejections based on established policies.
Reviewed medical claims to identify improper Medicare Payments.
Conducted quality assurance assessments on statistical samples.
Utilized CPT and ICD coding systems to maintain compliance.
Performed audits focusing on procedural diagnosis code selection.
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