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 : To obtain a position where can maximize skills in the medical field, customer service skills, and contribute to the success of a winning team. A creative results oriented professional with extensive experience.
Skills : Microsoft Office, Google Classroom, Promethean Board.
Description :
Assisted customers with any questions or problems that they might have had.
Provided customers with any information that was needed in order to solve any problems that they may have.
Called customers and requested that they send in the correct documentation in order to continue the process of paying their claim.
Faxed paperwork, using the computer, and the copier. Paying claims for national and international packages that are lost or damaged by UPS.
Interacted daily with co-workers answering and asking questions that are viable to do the job correctly.
Performed routine and special audits of par and non-par provider claim to determine payment accuracy for Medicare and Commercial plans.
Utilized Excel and Access to launch theoretical claim queries into the system.
Experience
5-7 Years
Level
Executive
Education
Masters
Claims Auditor I Resume
Objective : To obtain a full-time position as a claims processor or claims auditor within an established company where knowledge, skills and experience can be utilized to their full potential.
Audited the claims processors audit all facility, high dollar, sniff, home health, and claims.
Able to meet daily production while maintaining a high level of accuracy. Able to process and audit according to company policies and procedures.
Able to use several different applications in order to do the job correctly.
Worked using, facets, on base, Emdeon, med assets, priced claims manually using burgers.
Processed and audited commercial, Medicare, and Medicaid claim.
Served the needs of AFLAC's Puerto Rico clients by auditing medical insurance claims and processed approvals per worker compensation guidelines.
Consistently exceeded quota set by management by more and served as a translator.
Experience
2-5 Years
Level
Junior
Education
Medical Terminology
Claims Auditor III Resume
Summary : Seeking a position to utilize specific knowledge of accounting as well as general knowledge of business management. Ideally, would like to find a position that holds the potential for long-term growth.
Skills : MS-Word, Excel, Power point.
Description :
Oversaw employee benefits processing and disbursement.
Collected and audited claim submissions and disbursement process.
Produced an Explanation of Benefits and Claims Settlement payments.
Managed claim research, processing, and payment. Excellent written and verbal communications.
Audited post-payment physician and facility claims for payment accuracy, governmental regulation compliance.
Possible fraud scenarios on multiple client accounts within various states for Medicare, Medicaid, and commercial products.
Provided on-site audit services of Medicare Advantage plans to ensure CMS payment and policy adherence as part of the ongoing.
Experience
10+ Years
Level
Senior
Education
Diploma
Claims Auditor/Representative Resume
Summary : To further career, by obtaining a position that will utilize knowledge, skills, and leadership qualities that have developed through work, scholastic and other experiences.
Skills : Office work, Computers.
Description :
Audited worker's compensation claims to verify that all information is correct and insures claims are re-priced and paid in a timely manner.
Researched both UB-92 and claims not found in the Power Track system.
Contacted the Sedgwick coordinator to obtain information on the claimant that will help locate a valid account number.
Claimed to follow to commercial insurance companies to check status on filed claims.
Contacted Juris Coordinator if the previous steps are not successful, to have claim re-queued in the system.
Hard copy claimed that for various reasons are not able to be scanned.
Peer- trained with newer employees, answering any questions they may, so they can pay claims correctly.
Experience
7-10 Years
Level
Management
Education
Diploma
Claims Auditor/Representative Resume
Summary : Energetic and enthusiastic insurance professional motivated to succeed in a fast-paced and deadline-driven professional environment. Comprehensive knowledge of claims adjustments.
Based on client specifications, administer the claim process including matching claim to Prior Approvals, auditing the claim, data entry and verifying input.
Updated and maintained customer profiles and contact information in the SalesForce database.
Confirmed correct documentation/proof of performance was submitted; confirming amounts requested for payment based on invoices submitted.
Ran and verified all client reports; run and verify customer statements and detail reports; run and verify letters.
Worked in a fast-paced environment while auditing claim batches that can exceed.
Translated multiple documents and invoices to help identify and convert currencies and apply international tax rates.
Professional Qualifications and Skills Microsoft Office, proficient at Word and Excel.
Experience
7-10 Years
Level
Management
Education
Applied Science
Claims Auditor II Resume
Headline : To obtain a position where may continue to learn and expand knowledge while utilizing skills and expertise in ways that will prove an asset to employer.
Skills : Microsoft Word, Microsoft excel, System Operator.
Description :
Developed tend analysis and reporting mechanisms for the unit.
Constructed methods of communicating trends via written procedures and provides training for the unit and/or individuals.
Provided accurate audit results with clear explanations of any errors or issues identified in the audit.
Worked closely with management to customize individual internal audit reporting for claims and customer service.
Constructed gives and receives feedback concerning the quality of work.
Provided monthly trend reports that fully summarize audit data to allow management to quickly understand the quality of work.
Assisted the manager by providing written procedures for identified areas of improvement.
Experience
5-7 Years
Level
Executive
Education
Medical Office
Claims Auditor II Resume
Headline : Excellent written and verbal skills. Highly organized and detail oriented. Excellent problem solving skills and analytical skills. Resourceful in multitasking and working under pressure.
Reviewed Medicare claims to ensure it was processed correctly.
Responded to inquiries from the compliance team regarding eligibility, claims, provider network, service area, grievances, and appeals.
Audited the following claim types, DRG, Inpatient, Skill Nursing, Inpatient Rehab, Inpatient Mental Health, Long Term Acute Care.
Conducted training classes for all claim types.
Conducted telephone and video training classes for team India for all claims types.
Conducted training classes for providers on CIP claims submission process.
Checked member eligibility status on the MARX system.
Experience
5-7 Years
Level
Executive
Education
Medical Assistant
Asst. Claims Auditor Resume
Objective : Seasoned and resourceful candidate, offering significant experience in the insurance and customer service fields. Commitment to creating a strong team environment while strengthening.
Skills : Technical Skills, MS-Office.
Description :
Reviewed client systems to determine if claims were paid per coordination of benefits.
Revamped accounting quality system to prepare for important audits.
Communicated with Medicare, Patients, and Employers. Audited claim forms and cataloged insurance claims.
Constructed training manuals and implementations of new clients.
Audited and processed medical and dental claims, Interpreted and applied plan sponsor benefits and medical contracts.
Processed medical claims for two separate accounts, one with over lives.
Handled all benefits and claims status calls for both clients as well as all inquiries from insureds.
Experience
2-5 Years
Level
Junior
Education
Business Management
Associate Claims Auditor Resume
Objective : To seek a challenging position with an organization in search of a self-motivated, enthusiastic financial and accounting professional with experience and a strong commitment to the success of the organization.
Skills : Microsoft Office, Communication Skills.
Description :
Responsible for claims examination procedures, information and data management.
Performed extensive audits on health insurance and Medicaid claims, audit documentation, audit report draft documentation, and error write-up.
Researched and determined settlement or denial of medical and pharmaceutical claims.
Ensured claims are audited in accordance with contract provisions related to potential processing and payment errors.
Ensured the quality and integrity of data of internal and external sources.
Researched medical claims with heightened alerts to identify fraud schemes and accurately documented and reported identified fraud activities.
Demonstrated strong analytical and data interpretation skills.
Experience
2-5 Years
Level
Junior
Education
Information Science
Asst. Claims Auditor III Resume
Summary : To utilize strong clerical and interpersonal skills in order to allow employers to successfully examine and operate their organization at its full potential.
Skills : Communication Skills, Management.
Description :
Acted as a liaison between insurance companies and auto body shops.
Negotiated vehicle estimates for insurance companies and assists body shops in the complete payment of vehicle repairs.
Created program management scorecards to see who were our best performing body shops and referring that information to the insurance companies.
Reported analytics to track the information that matters most to our customers.
Provided solutions that are compatible with the customer's current client systems.
Processed up to estimates a day while the average is about estimates a day.
Audited led to an average saving in claims.
Experience
10+ Years
Level
Senior
Education
Bachelor Of Arts
Claims Auditor Resume
Objective : To obtain a challenging position with a company that will allow to use varied knowledge and skills for career and personal growth.
Skills : Technical Skills, Management.
Description :
Performed to resolve errors by communicating with the Production Manager or Supervisor.
Audited member liability denials to assure the quality of the claim.
Ensured the accuracy of payment/rejection based on contractual policies and procedures.
Reviewed medical claims to detect unlawful or incorrect Medicare Payment.
Conducted quality assurance assessments and reviewed statistical samples.
Utilized CPTS ICD-9/ICD-10 and other coding systems with an emphasis on compliance and regulatory standards.
Performed audits specifically targeting and evaluating procedural diagnosis code selection.
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