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.
Headline : To secure a full-time position utilizing skills and experience in the medical claims field. Ability Summary Outstanding attendance Consistently exceeds production and accuracy standards Willingness to work overtime.
Skills : Claims Processing, Customer Service, All Microsoft Office, 60wpm.
Description :
Health Insurance Claims Adjustor Answering high volume incoming calls to previously processed claims.
Identifying the causes of incorrect action taken on denied claim and reprocessing the claims per contract benefits.
Processed complexed claims where I had to use my experience in coordination of Worker's comp.
Working in a production environment where the number of claims processed and incoming calls answered was relative to the company's success.
Provided service excellence to customers by accurately the claims processing system in a timely manner.
Worked on a team to resolve claim reject issues while researching data to find ways to better serve the client.
Due to the limited number of employees, claims processing, customer/provider support, training, and health plan audits.
Experience
5-7 Years
Level
Junior
Education
BS
Asst. Medical Claims Examiner Resume
Headline : Accomplished at transposing large amounts of data with accuracy and speed. Highly Late-night shift availability Good with numbers and math Fast and efficient service worker Professional and mature Accurate and detailed.
Specializes in providing administrative services for employee benefit plans on a national basis.
Medical Claims Examiner: Specialized in verifying and processing and hospital claims.
Performed re-pricing and administered coordination of benefits.
Contacted providers and claimants to obtain additional information and supporting documentation.
Interpreted policies and investigated claims in a high volume environment.
Processing of medical claims and routine dental claims, entering checking group plans for system payment errors.
Maintained claim files, records of settled claims and inventory of claims requiring detailed analysis, as well as resolving complex.
Experience
5-7 Years
Level
Management
Education
Diploma
Associate. Medical Claims Examiner Resume
Headline : Several years of experience in the health care field and Medical Coding such as Medical Terminology, and Insurance Billing from Healthcareer Association.
Skills : Technically skilled and proficient in learning new, Customer Service Skills, Cleaning, Computer Skills, Typing 50 Wpm
Description :
Updated job knowledge by participating in educational opportunities.
Resolved medical claims by approving or denying documentation; initiating a payment or composing denial letter.
Accomplishes organization goals by accepting ownership for opportunities to add value to job accomplishments.
Processed complex claims requiring further investigation.
Train and audit employees Perform Deductible Reviewing and correcting customer's concerns with their claims Focus Group.
Maintain part of a group to help identify issues in our department and come up with solutions on how to solve the issues.
Provide customer service to providers and members.
Experience
5-7 Years
Level
Executive
Education
HS
Medical Claims Examiner ll Resume
Headline : Experienced in providing superior customer service in a variety of medical and health insurance positions. Independently or on a team, and results-driven.
Skills : Multi-Tasking, Microsoft Office, Bookkeeping, Budgeting, Customer Service, Management, Auditing, Medical Terminology.
Description :
Paid claims received from medical providers according to plan provisions and applicable state mandates.
Provided superior customer service to insured members and through phone and email contact.
Specialist processed and paid hospital claims, including high dollar claims, accurately and in a timely manner.
Developed optimal working relationships with brokers and group contacts as a lead examiner for several large insurance clients.
Consistently exceeded set quality and production goals.
Volunteered on committees to review and improve claims payment efficiencies, maintain customer service standards.
Adding of providers, CPDB software, Pricing of claims Accessing a variety of Network system claims.
Experience
5-7 Years
Level
Junior
Education
BS
Medical Claims Examiner lll Resume
Headline : Obtain a position as a team player in a people-oriented organization where can maximize customer service experience in a challenging environment to achieve corporate goals.
Skills : Excel, Word, Blue Cross, Basys, Customer Service Skills, Cleaning, Computer Skills, Typing 50 Wpm.
Description :
Answers inquiries by clarifying desired information; researching, locating, and providing information.
Resolves problems by clarifying issues, researching and implementing solutions; escalating unresolved problems.
Sells additional services by recognizing opportunities to up-sell accounts, explaining new features.
Maintains call center database by entering information.
Updates job knowledge by participating in educational opportunities.
Enhances organization reputation by accepting ownership for opportunities to add value to job accomplishments.
Customer Focus, Customer Service, Data Entry Skills, Solving, Multi-tasking.
Experience
5-7 Years
Level
Management
Education
Diploma
Medical Claims Examiner/Executive Resume
Headline : Skilled Medical Assistant with an Associates degree in medical full potential and show the skills and knowledge gained through education and experience.
Determines covered medical insurance coverage by studying provisions of the policy.
Documents medical claims by completing forms, reports, and records.
Process medical claims by approving or denying documentation, or composing denial letter.
Follows company policies, procedures, guidelines, as well as state and ensure legal compliance.
Protects clients and claims information by following confidentiality standards.
Maintain job standards by taking advantage of yearly educational benefits and opportunities.
Maintain goals set by Hewlett-Packard by accepting new contributes to and involves my entire team and is a team effort.
Experience
5-7 Years
Level
Management
Education
Diploma
Asst. Medical Claims Examiner Resume
Summary : Experienced claims examiner with an extensive background in the healthcare industry to include managed care, claims processing and capitation. Obtain a position that will provide work experience to a growing company
Thorough knowledge with Medicare and Medical Regulations and processing of complex claims.
Processing ambulance, home health, claims in a timely and accurate manner.
Skilled in several computer software applications and web interfaces for verification of member healthcare history and plan eligibility.
Obtaining, reviewing and verifying correspondence and authorizations.
Communication with insurance health plans, medical groups and third-party payers regarding hospital payments.
Reviewing claim payments for accuracy based on contractual obligations and/or state regulatory guidelines.
Assisted with front desk duties, customer service phone calls, and mailroom duties.
Experience
10+ Years
Level
Senior
Education
Diploma
Associate. Medical Claims Examiner Resume
Summary : To find a challenging Claims Examiner in a detail-oriented effective communicator with creative problem-solving skills and extensive experience. Knowledge and experience will demonstrate to be a valuable resource for the team and health care organization.
Examined data enter, calculated and adjudicated claims complying with Federal laws.
Verify patient accounts, eligibility benefits, and authorizations.
Responsible for accurate and timely adjudication of claims for HMO, Medical, and Medicare.
Update status of claims, provide an explanation of denied claims and work closely with other claim examiners.
Knowledge if Modifiers, and provider contracts.
Requested additional information for incompleted or unclean claims.
Adjudicates Medicare claims following the Center for Medicare Servicing manual for accurate processing according to guidelines.
Contacting other insurance companies for payment information.
Experience
10+ Years
Level
Senior
Education
Diploma
Medical Claims Examiner/Representative Resume
Objective : To secure a challenging position within a progressive and dynamic organization, that will enhance knowledge and skills, as to pursue the overall goal of obtaining a higher degree.
Skills : Ms. Office, Training & Development, Medicare, Medicaid, Analytics
Description :
Responsible for examining and processing medical claims for Inpatient, Dialysis and Outpatient visits.
Receive and process claims within an assigned queue at the expected bill rate.
Follow-up on pended claims in a timely fashion and as needed.
Maintain and utilize resource materials necessary to perform job responsibilities effectively.
Resolve or assist in the resolution of complex and sensitive issues.
Exhibit outstanding leadership qualities and promoting world class customer service.
Evaluate and respond to written requests on an as needed basis.
Experience
2-5 Years
Level
Management
Education
BS
Medical Claims Examiner/Coordinator Resume
Headline : Well rounded professional with strong communication skills. Extremely detailed oriented focusing on accuracy and thoroughness. Actively participates as a team member that moves towards the completion of goals.
Skills : Microsoft Office, Excel, Word, Outlook, Powerpoint, Prezi.
Description :
Provide claims editing with the usage of coding, claims adjudication and payment.
Utilization of Microsoft Excel to include pivot tables, charts, and formulas, knowledge of claims, billing knowledge of Medicaid and Medicare.
Create spreadsheets for the management of claims received and corrected.
Quality Assurance evaluation of claims processed by the team.
Efficiently complete projects generated by clients for problematic claim errors.
Complete appeals to the home office for a denied claim.
Investigate authorizations and request additional information when needed.
Experience
5-7 Years
Level
Management
Education
MS
Medical Claims Examiner/Consultant Resume
Headline : To increase customer satisfaction and growth by efficiently delivering competitive professionals. Resulting in becoming a valuable employee utilizing and expanding current knowledge and skills.
Skills : , Training & Development, Medicare, Medicaid, Analytics
Description :
Reviewed Medicare part claims and either denied or authorized payment in accordance with documented and approved procedures.
Read and interpreted edits and edit resolutions which included manual processing.
Researched terminology, procedures and denial codes that generated.
Initiated automated written contact with various external sources if the claim was submitted with incomplete information.
Utilized responses to adjudicate the claim and initiated action to recover payments made in error.
Relayed educational feedback to examiners when processed incorrectly.
Reviewed, processed and paid medical claims from hospitals and physicians.
Experience
5-7 Years
Level
Executive
Education
BS
Medical Claims Examiner Resume
Headline : Extensive knowledge of within the health industry. Excellent interpersonal skills and a strong focus on quality and patient satisfaction. Computer literate.Motivated non-smoker with an outstanding work ethic.
Skills : , Training & Development, Medicare, Medicaid, Analytics
Description :
Processed employee's medical claims, which included and coding on an accurate and timely basis.
Performed claim adjustments to re-issue proper payment amounts.
Customer Service Representative Provided accurate resolution of claim issues.
Made necessary adjustments on complicated claim issues.
Provided correct information regarding the benefits and policies of the Health Benefits Plan.
Quality Control Analyst Analyzed Claims Processors' quality of work.
Provided supervisor with processors' knowledge of benefits through their claim processing ability.
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