Claims Resolution Specialist Resume Samples

Description :

1. Review medical information via images scanned into the Medflow database.
2. Determine if any information is missing or needs to be further verified Make outbound calls to other insurers as needed to obtain the missing information.
3. Document information received in both the CPSI database and the customer service software specific to each image viewed.
4. Communicate clear and precise directions regarding the information obtained.
5. Interface with other customer service representatives and other insurers while maintaining a professional attitude.
6. Worked directly with providers to resolve claim and care management concerns.
7. Performed negotiations for various insurance companies with the purpose of receiving the maximum amount of savings for the insurance carrier as well.

Experience

10+ Years

Level

Senior

Education

BA

Description :

1. Communication with other departments, including Corporate Claims, Cost-Containment, Quality Improvement, Special Investigations Unit, Customer Service, Provider Network, and Appeals.
2. Documentation of past disputes and responses and pulling documentation when needed.
3. Adjudicated claims and processed adjustments to include tracking and trending performance.
4. Provided re-enforcement training for new associates as well as on-floor support to existing associates.
5. Worked with multiple departments to identify and implement process improvements.
6. Handled all expedited claims concerns from dmas (va medicaid) and the grievance team in a timely manner.
7. Operated as a liaison between multiple teams to include claims, customer service, care managers, provider network, and grievance departments.

Experience

7-10 Years

Level

Senior

Education

Bachelor's

Description :

1. Delayed submission of insurance accounts or payment of accounts, Rectify delayed submissions by providing feedback and educating analysts, preventing reoccurrence of these issues.
2. Monitor claim mapping issues in Athena Collector.
3. Investigate claims in manager holds that involve provider numbers, or taxonomy issues.
4. Coordinate with Provider Enrollment to keep appropriate staff current on credentialing issues and status.
5. Handled all types of medicaid high complexity claims request, inquiries and complaints accurately and timely.
6. Trained both customer service and clinical teams on accurately entering authorizations to decrease claims abrasion.
7. Responsible for resolving severe customer complaints which included Lemon Law cases, legal cases and any customer complaint requiring the involvement.

Experience

2-5 Years

Level

Junior

Education

Organization Management

Description :

1. Ensures accurate and timely claims processing for professional and institutional claims.
2. Proactive investigation, evaluation and assessment of claims, as well as strategic defense and resolution of such claims.
3. Process a variety of transactions that involve hold code and adjustment processing.
4. Perform Coordination of Benefits on a variety of claims from major healthcare carriers including Medicare.
5. Adjustments of claims, request refund s, adjudication experience of corrected claims and ratification of incorrect payments.
6. Maintains 99% financial and 97% procedural claim accuracy (departmental set).
7. Attends extensive training sessions to receive additional training in Facility claims, COB and Medicare.

Experience

10+ Years

Level

Senior

Education

BS

Description :

1. Review claims that have been denied by health insurance companies.
2. Learned the system very quickly which helped in resolving more claim issues.
3. Recovered several thousands of dollars by figuring out some system issues which caused claims to be denied, as well as finding claims that were not processed correctly to begin with.
4. Resolve third party rejects by analyzing the claim, gathering information, making corrections and resubmitting.
5. participated on the weekly calls to include provider concerns, eligibility file feed concerns, internal and external.
6. Assisted in training co-workers in claims processing methods.
7. Assisted members and providers in resolving inaccuracies in claims processing.

Experience

2-5 Years

Level

Executive

Education

Certificate

Description :

1. Respond to emails in a timely manner and work reports daily.
2. Resolve disputed balances. Report any identified billing issues that result in non-collection to Management.
3. Resolve all red flag requests in a timely manner.
4. Identify needed adjustments to claims.
5. Develop and maintain effective working relationships with all internal and external customers.
6. Responsible for resolution of written correspondence and telephone inquiries from physician offices that may be subject to review, research.
7. Worked closely with manager to investigate trends and to provide analysis.

Experience

2-5 Years

Level

Executive

Education

Bachelors Of Science

Description :

1. Assigned accounts claims/bills on behalf of CIGNA to achieve Automotive maximum discount and savings retention reimbursements.
2. Identified process improvements that impact quality and service results.
3. Communicated both verbally and in writing with providers, stake holders, the governor, and the client.
4. Processed mental health claims for members.
5. Assisted in training co-workers in claims processing methods.
6. Volunteered for new and or difficult accounts.
7. Assisted members and providers in resolving inaccuracies in claims processing.

Experience

7-10 Years

Level

Management

Education

Certificate

Description :

1. Respond promptly and accurately to inquiries from Customer Service professionals, subscribers, providers, agents, brokers, physicians and other commercial insurance carriers regarding claims payment.
2. Responsible for billing patients and submitting all claims to insurance Processing financial aid/hardship requests on behalf of the patient Cross.
3. Assisted account managers with clients Processed medical claims Provided concierge service in locating physicians for members Explained guidelines to.
4. Worked Correspondence from Medicare Contact Medicare for denials Complete follow-up resolution and denial management Correct and resubmit claims Work .
5. Able to meet or exceed quality, accuracy, and production standards as determined by Avesis.
6. Assist in understanding and evaluating warranty coverage Create work items from Claims and/or work orders Handle various dispatch activities Answer.
7. Handle special projects as necessary; track and report on analysis of claims throughout the duration of the special project.

Experience

7-10 Years

Level

Management

Education

BA

Description :

1. Provide feedback and status updates of inventory to management daily.
2. Identify trends and participate in problem solving with reports and corrected claims data.
3. Present and speak to the issues offering solutions and process improvement.
4. Develop and maintain document processes to generate reports.
5. Completed all task with little to no supervision in timeframe allotted.
6. Reviewed all medical insurance claims for resolution and payment Resolve any incoming inquiries or payment denials from insurance providers.
7. Reasonable procedure exceptions to accommodate unusual customer requests.

Experience

10+ Years

Level

Senior

Education

Business

Description :

1. Set up monthly payment plans for patients unable to pay their balance in full.
2. Monitor patient credit balances for refunds and give to the Billing Manager for approval.
3. Mail refund checks and enter information into the Notes section in patient's account.
4. Provide excellent customer service by quickly communicating accurate billing information.
5. Effectively prioritizing daily billing operations to ensure customers' needs are addressed promptly and with proper resolution.
6. Identify, research and resolve customer's billing issues Performs other duties as assigned.
7. Processed and paid correctly Reviewing, correcting, and appealing unpaid and denied claims Daily Electronic and paper claim submission Answering patients billing questions via inbound telephone calls.

Experience

2-5 Years

Level

Executive

Education

Associate Of Science