Medical Claims Examiners are involved in determining the amount of insurance coverage, examining and resolving medical claims, maintaining high-quality customer service, ensuring legal compliance, and documenting actions. The job duties for this post included in the Medical Claims Examiner Resume are – determining covered and uncovered medical claims, establishing proof of loss, documenting medical claims, ensuring legal compliance, providing legal support, maintaining confidentiality of claims information, preparing reports, updating job knowledge performing data entry and other administrative tasks, organizing and maintaining records of settled claims.
To fulfill this role, the Medical Claims Examiners have to possess certain skills and abilities such as – outstanding reading comprehension skills, good writing skills, critical thinking and decision-making power, logical thinking and reasoning abilities, ability to evaluate and resolve claims, negotiating skills, and strong computer proficiency. A good understanding of medical terms and paralegal experience will be an added advantage. There are no specific set of requirements needed for this post as incumbents are hired and given on-the-job training.
Objective : Motivated medical claims examiner with two years of experience in claims processing and customer service. Proven ability to analyze and resolve complex claims issues while ensuring compliance with regulations. Adept at improving operational efficiency through detailed audits and effective communication with providers. Eager to leverage skills in a dynamic healthcare environment.
Skills : Analytical Skills, Problem Solving, Insurance Regulations, Data Entry
Description :
Managed high volumes of health insurance claims, ensuring timely and accurate processing.
Investigated and rectified discrepancies in denied claims, adhering to contractual obligations.
Processed complex claims, utilizing expertise in coordination of benefits and workers' compensation.
Contributed to team goals by enhancing claims processing efficiency through collaboration.
Delivered exceptional service by addressing customer inquiries regarding claims status and resolution.
Collaborated with team members to identify and resolve claim rejection issues, improving overall service delivery.
Supported training initiatives for new staff, enhancing team knowledge and performance.
Experience
0-2 Years
Level
Entry Level
Education
AAS HIT
Junior Medical Claims Examiner Resume
Objective : Dedicated Junior Medical Claims Examiner with two years of experience in processing and verifying medical claims. Proficient in ensuring compliance with healthcare regulations and improving claim accuracy through effective audits. Seeking to contribute analytical skills and attention to detail in a fast-paced healthcare setting.
Specialized in verifying and processing medical claims, ensuring adherence to regulatory standards.
Performed re-pricing and coordinated benefits for complex claims.
Communicated with providers and claimants for information and documentation collection.
Interpreted insurance policies and investigated claims in a high-volume environment.
Processed medical and dental claims while checking for system payment errors.
Maintained organized claim files and records of settled claims, resolving complex issues.
Conducted detailed audits to ensure accuracy and compliance in claims processing.
Experience
0-2 Years
Level
Junior
Education
AAS in HIM
Medical Claims Examiner Resume
Objective : Dynamic Medical Claims Examiner with two years of dedicated experience in claims processing, analysis, and compliance verification. Skilled in resolving complex claims discrepancies and enhancing operational workflows through precise audits and effective provider communication. Passionate about contributing to a healthcare organization that values accuracy and efficiency.
Skills : Data Cleaning, Healthcare Software Proficiency, Typing Accuracy At 50 Wpm, Healthcare Regulations, Claim Review, Eligibility Verification
Description :
Processed complex claims requiring thorough investigation and analysis.
Conducted audits to ensure compliance with healthcare regulations and policies.
Collaborated with team members to identify and resolve departmental issues efficiently.
Provided guidance and training to new staff members on claims processing protocols.
Utilized healthcare software to manage claims effectively and maintain accurate records.
Engaged with providers to clarify and resolve outstanding claims inquiries.
Assisted in developing best practices to streamline claims processing operations.
Experience
0-2 Years
Level
Entry Level
Education
A.S. in Med Billing
Medical Claims Examiner I Resume
Objective : Detail-oriented Medical Claims Examiner with 5 years of experience in processing and analyzing claims. Expertise in ensuring regulatory compliance and optimizing claims accuracy through effective audits. Proven track record of enhancing operational efficiency and fostering strong provider relationships. Committed to contributing analytical skills in a fast-paced healthcare environment.
Processed medical claims accurately according to established guidelines and state regulations.
Ensured timely resolution of claims issues by collaborating with healthcare providers and members.
Analyzed complex claims, identifying discrepancies and implementing corrective measures.
Maintained effective communication with brokers and group contacts to enhance service delivery.
Regularly exceeded productivity targets, processing over 150 claims per day.
Participated in initiatives to improve claims payment efficiency and customer service standards.
Utilized CPDB software for provider additions and claims pricing within various network systems.
Experience
2-5 Years
Level
Junior
Education
A.S. H.I.T.
Medical Claims Examiner Resume
Headline : Accomplished Medical Claims Examiner with 7 years of experience in evaluating and processing medical claims. Expertise in ensuring compliance with healthcare regulations and enhancing claims accuracy through thorough audits. Proven ability to resolve complex discrepancies and streamline operations, contributing to improved efficiency in healthcare settings.
Skills : Claims Processing Software, Insurance Policy Analysis, Claims Management Systems, Claims Resolution Expertise, Data Integrity Management, Healthcare Data Analysis
Description :
Evaluated and processed medical claims, ensuring compliance with healthcare regulations and accuracy in documentation.
Identified discrepancies in claims and collaborated with healthcare providers to resolve issues efficiently.
Conducted thorough audits of claims submissions to maintain high standards of quality and compliance.
Provided exceptional customer service by addressing inquiries and educating clients on claims processes.
Developed and maintained accurate records of claims processed, ensuring proper documentation for audits.
Utilized advanced claims processing software to enhance efficiency and accuracy in claim evaluations.
Participated in continuous education to stay updated on industry regulations and best practices.
Experience
5-7 Years
Level
Senior
Education
B.S. in Health Admin.
Senior Medical Claims Examiner Resume
Summary : Seasoned Senior Medical Claims Examiner with over 10 years of robust experience in evaluating, processing, and adjudicating complex medical claims. Demonstrated expertise in regulatory compliance, claims accuracy, and operational efficiency. Committed to leveraging analytical skills and industry knowledge to optimize claims processing and enhance provider relationships.
Evaluated and processed complex medical claims, ensuring alignment with policy provisions and compliance with regulations.
Conducted thorough audits to validate claims accuracy, enhancing operational efficiency and minimizing discrepancies.
Collaborated with healthcare providers to resolve claims issues, fostering strong professional relationships.
Maintained comprehensive documentation of claims decisions and communications to support transparency and compliance.
Trained and supervised new staff on claims processing protocols and best practices, promoting a culture of accuracy.
Monitored industry regulations and updates to ensure compliance and adapt processes accordingly.
Utilized data analytics to identify trends and improve claims processing workflows, contributing to organizational goals.
Experience
7-10 Years
Level
Management
Education
B.S. in HA
Medical Claims Examiner Resume
Objective : Committed medical claims examiner with two years of hands-on experience in processing and analyzing claims. I excel in ensuring compliance with industry regulations while effectively resolving disputes. My focus on operational efficiency and quality assurance positions me to contribute significantly to a healthcare team dedicated to excellence.
Skills : Microsoft Office Suite, Microsoft Word, Microsoft Access, Internet Explorer, Windows Operating System, Microsoft Outlook
Description :
Thorough understanding of Medicare and Medicaid regulations, ensuring accurate claims processing.
Efficiently processed ambulance and home health claims, maintaining a high level of accuracy.
Utilized multiple software applications for verifying member healthcare history and eligibility.
Reviewed and verified authorizations and correspondence to ensure compliance.
Communicated effectively with insurance plans and providers regarding claim statuses.
Conducted detailed audits of claim payments for accuracy based on contractual obligations.
Provided exceptional customer service to resolve inquiries and claims issues promptly.
Experience
0-2 Years
Level
Fresher
Education
AAS HIT
Assistant Medical Claims Examiner Resume
Objective : Detailing two years of experience as a Medical Claims Examiner, I specialize in processing claims and ensuring adherence to healthcare regulations. My analytical skills enable me to identify discrepancies and enhance claim accuracy. I am committed to optimizing processes and fostering collaborative relationships with providers in a healthcare setting that prioritizes quality service.
Examined and adjudicated claims, ensuring compliance with federal regulations.
Review and analyze medical claims for accuracy and compliance with policies.
Processed claims accurately for HMO, Medical, and Medicare, ensuring timely payments.
Updated claim statuses and communicated effectively regarding denied claims.
Utilized knowledge of modifiers and provider contracts to resolve discrepancies.
Requested additional information for incomplete or unclear claims to ensure accuracy.
Adjudicated Medicare claims in accordance with the Center for Medicare Services guidelines.
Experience
0-2 Years
Level
Entry Level
Education
A.A.S.
Medical Claims Examiner Resume
Objective : Experienced medical claims examiner with two years of expertise in accurately processing and adjudicating medical claims. Proficient in compliance verification and issue resolution, ensuring adherence to healthcare regulations. Committed to enhancing operational efficiency and fostering positive relationships with healthcare providers in a results-driven environment.
Examine and process medical claims for inpatient, outpatient, and dialysis services.
Efficiently manage claims within assigned queues, ensuring timely processing.
Conduct follow-ups on pending claims to facilitate resolution.
Utilize resource materials for effective job performance and compliance.
Resolve complex issues and provide assistance in sensitive claim disputes.
Provide exceptional customer service while promoting operational excellence.
Evaluate and respond to written claim inquiries as required.
Experience
0-2 Years
Level
Entry Level
Education
B.S. Health Admin.
Junior Medical Claims Examiner Resume
Objective : Detail-oriented Medical Claims Examiner with over 5 years of experience in reviewing and processing medical claims. Proficient in analyzing medical records, verifying coverage, and ensuring compliance with regulations. Strong analytical skills and a commitment to accuracy, resulting in reduced claim processing times and improved customer satisfaction. Excellent communication skills for effective collaboration with healthcare providers and insurance teams.
Skills : Customer Service, Advanced Excel Skills, Microsoft Word Proficiency, Outlook Email Management
Description :
Processed and adjudicated medical claims with attention to coding accuracy and compliance.
Utilized advanced Excel skills to create and manage detailed claims tracking spreadsheets.
Conducted quality assurance evaluations on team-processed claims to ensure adherence to standards.
Addressed client-generated projects to resolve complex claim errors efficiently.
Managed appeals for denied claims, ensuring timely and thorough documentation.
Investigated authorization requests and coordinated with providers for additional information.
Maintained up-to-date knowledge of Medicaid and Medicare billing practices.
Experience
2-5 Years
Level
Junior
Education
BSHA
Medical Claims Examiner Resume
Headline : Experienced Medical Claims Examiner with a solid background in evaluating and processing healthcare claims. Skilled in identifying discrepancies, ensuring compliance with policies, and maintaining accurate records. Proven ability to work under pressure while meeting deadlines. Strong problem-solving skills and a focus on delivering high-quality service to clients and stakeholders in the healthcare industry.
Reviewed and processed Medicare claims, authorizing or denying payments based on established protocols.
Interpreted claims edits and resolutions, ensuring accurate manual processing when necessary.
Conducted thorough research on terminology, procedures, and denial codes to ensure accurate claims adjudication.
Initiated automated communications with external sources for incomplete claim submissions, facilitating resolution.
Utilized claim responses to adjudicate and recover erroneous payments effectively.
Provided educational feedback to examiners on claims processing errors to enhance overall accuracy.
Processed and paid medical claims for hospitals and physicians, ensuring compliance with regulations.
Experience
5-7 Years
Level
Consultant
Education
B.S. Health Admin.
Medical Claims Examiner Resume
Objective : Results-oriented Medical Claims Examiner with two years of experience in processing and analyzing claims. Demonstrated ability to resolve discrepancies efficiently while ensuring adherence to healthcare regulations. Committed to enhancing operational workflows and fostering effective communication with providers to optimize claims accuracy.
Skills : Communication Skills, Time Management, Medical Terminology, Critical Thinking, Team Collaboration
Description :
Identify and investigate potential fraud or abuse in claims submissions.
Performed adjustments on claims to ensure proper payment amounts were issued.
Provided excellent customer service by resolving claim issues promptly and accurately.
Analyzed complex claim discrepancies and made necessary adjustments to facilitate resolution.
Educated clients on benefits and policies of the Health Benefits Plan.
Conducted quality control audits to assess the accuracy of claims processed by team members.
Collaborated with supervisors to enhance knowledge sharing among claims processors.
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