Claims Processing Specialist Resume Samples

Description :

1. Established a reputation for outstanding work performance in Department of Defense claims processing.
2. Selected by Cindy as a permanent hire to work with her on developing a specialized Exceptions team, responsible for handling onshore claims for WellPoint and special needs clients.
3. Acted as her backup, I fielded incoming questions and issues for the Exceptions Team.
4. Appointed to work the Forward to Research Analyst queue, which required the duties of a research analyst to complete successfully.
5. Worked with Prior Authorization, Legal, and Account Management to resolve customer grievance and appeals claims.
6. Trained and nested with new members of the Exceptions team, including internal employees for cross-training and new hires.
7. Selected to take part in a focus group led by senior management to resolve staff-identified challenges and grievances.

Experience

2-5 Years

Level

Executive

Education

High School Diploma

Description :

1. Submitted HCFA-1500 claim forms to insurance companies while remaining mindful of timely filing limits, errors with patient and insurance information, denials and rejections, insurance payer requirements, updates to payer information and guidelines, and changes regarding health information.
2. Processed 400+ claim edits weekly working with various systems to verify accurate patient information.
3. Ensured the correctness of claims information and patient demographic information for timely filing of claims submission.
4. Worked from reports with a weekly goal to complete specific patient accounts that require immediate attention to avoid timely filing.
5. Worked closely with patient insurance eligibility verification systems.
6. Assisted in transitioning from paper claims processing to mostly electronic claims processing by researching individual payer requirements.
7. Utilized various systems to verify medical insurance, research patient files, update patient information, and process claims edits in an effective and timely manner.

Experience

2-5 Years

Level

Executive

Education

MS

Description :

1. Reviewed and adjudicated routine claims in accordance with claim processing guidelines using QNXT.
2. Analyzed and approved claims while maintaining quality standards.
3. Applied medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
4. Routed and triaged High dollar claims and seeks support and advice from designated specialist.
5. Proofed claim or referral submission to determine, review and apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.
6. Investigated claims for possible abuse and fraud.
7. Utilized all applicable system functions available ensuring accurate and timely claim processing service.

Experience

5-7 Years

Level

Executive

Education

GED

Description :

1. Responsible for working at a pace that allowed the assigned offices to meet deadlines Review and follow up of incomplete procedures, RTB (Ready to Bill), MTD (Month to Date) and Hold Certification errors by report as stipulated by Leads and/or Manager daily.
2. Reviewed and followed up on the Billing Console for non-posted appointment Daily/Weekly.
3. Identified common errors and communicate effectively to Leads to assist on the continuous development of the team.
4. Ensured all claims for my assigned offices are properly and accurately created.
5. Verified that eligibility and benefits have been properly verified before submitting the claim for processing.
6. Ensured the procedures to be billed were aligned with the service limits established by payers.
7. Ensured that all charted procedures corresponded to the procedures coded for billing.

Experience

5-7 Years

Level

Executive

Education

MS

Description :

1. Provided excellent customer service while taking calls for First Notice of Loss reports and Inquiry concerns regarding any loss for property, auto, renters, boat, and recreational policies.
2. Established inspections of property or auto while following company procedures to maximize results.
3. Utilized professional judgment to resolve customer complaints and bring claims to fast, fair, and reasonable resolutions.
4. Attained expert knowledge of Next Gen systems and auto coverage associated with claim handling practices and documentation requirements.
5. Supervised, mentored, and trained staff in time management, daily job duties, and task workgroups for Contact, Claim Status Work Group, Coverage Reviews, Internet Loss Reporting, First Notice of Loss, Support, and Processor.
6. Piloted a 3 month rotating position for Claims Experience Specialist with the Contact Team o Observed and evaluated a team of Claims Service Specialists (CSS) work for outbound claim call handling and first attempts for contact on a new claim.
7. Evaluations provided insight on each individual's areas of opportunity in order to ensure the delivery of the highest and most efficient customer service.

Experience

5-7 Years

Level

Executive

Education

Bachelor's In Business Administration

Description :

1. Obtained necessary billing information from provider/division billing contact/patient.
2. Provided supporting documentation at the time of claim submission to facilitate timely reimbursement.
3. Updated accounts in billing system.
4. Maintained billing manuals and reference documents for assigned third party carriers.
5. Contacted third party payers as needed to resolve billing problems/claim processing delays.
6. Reviewed claim forms to meet billing requirements as dictated by third party payers.
7. Reviewed unbillable claims (edit list) in a timely manner.

Experience

2-5 Years

Level

Junior

Education

MS

Description :

1. Processed Repair Claims, Updating, and confirming claims for old and new Customers.
2. Reviewed claim and policy information to provide background for investigation and may determine.
3. Evaluated facts supplied by investigation to determine extent of liability of the insured, if any, and extend of the company's obligation to the insured under the policy contract.
4. Established proof of loss by studying documentation submitted; assembling additional information as required.
5. Resolved claim by approving or denying documentation; calculating benefit due; initiating payment.
6. Provided administrative support in a claims department.
7. Reviewed insurance claims for accuracy and completeness before processing and submitting them to the claims examiner.

Experience

2-5 Years

Level

Executive

Education

MS

Description :

1. Answered phones and respond to customer requests.
2. Placed customer orders in computer system.
3. Provided customers with product and service information.
4. Transferred customer inquires not immediately resolved.
5. Completed call logs and reports.
6. Researched billing issues.
7. Transferred customer calls to appropriate staff.

Experience

2-5 Years

Level

Executive

Education

MS

Description :

1. Helped others get the satisfaction they desire.
2. Helped answer any questions the clients had about their claim after Medicare or other insurance has processed and paid their share of the claim.
3. Used patience and experience to work with customers over the phone to resolve any problems with claims.
4. Made sure that the claims that came into our office had the correct information and were entered into our computer system correctly.
5. Identified, researched, and resolved customer issues using the computer system.
6. Resolved claims listed as unbillable and bill in a timely manner.
7. Recommended and assisted in implementation of manual and automated billing process to enhance claim generation/submission process.

Experience

5-7 Years

Level

Executive

Education

Associates In Business Administration

Description :

1. Coached up to 40 CSS every month to provide continuous improvement of the team.
2. Provided oversight to the CSS team in the absence of leadership.
3. Ensured that all claims are in concordance with the highest ethical and quality standards set by Kool Smiles and Benevis.
4. Responsible for follow ups on pending and unbilled procedures on a timely basis.
5. Maintained 24-48 hour timeliness and processed claims and edits by oldest dates first.
6. Stayed up-to-date with training classes meant for professional improvement.
7. Appointed as a member of the six person task force.

Experience

5-7 Years

Level

Executive

Education

Business Administration