Medical Claims Processor Resume Samples

Description :

1. Ensured compliance with Medicare Advantage guidelines for authorization and provider network determinations.
2. Delivered exceptional customer service while adjudicating new and re-worked claims efficiently.
3. Determined correct benefits payable by adhering to established process rules and procedures.
4. Reviewed reports and documents to assess claims eligibility and ongoing benefits accurately.
5. Requested and followed up on necessary additional information for claim adjudication.
6. Maintained proficiency in claims processing software and administrative systems.
7. Interacted professionally with stakeholders to resolve inquiries regarding benefits, eligibility, and claim payments.

Experience

7-10 Years

Level

Executive

Education

AS-HIT

Description :

1. Reviewed and corrected electronic claims, resolving denials by communicating with insurance companies.
2. Developed effective strategies for correcting claims and submitted appeals for denied cases.
3. Addressed patient billing inquiries and gathered necessary insurance information for claims processing.
4. Obtained pre-authorizations from insurance for outpatient procedures and specialized services.
5. Coordinated patient referrals to specialists, ensuring timely communication and documentation transfer.
6. Managed front desk operations, including appointment scheduling and payment processing.
7. Conducted daily reviews of claims to assess eligibility for payment or denial based on policy provisions.

Experience

2-5 Years

Level

Junior

Education

AAS-MB

Description :

1. Managed comprehensive claims processing, ensuring compliance with regulations and accuracy in data entry.
2. Protected patient confidentiality by adhering to HIPAA guidelines and local procedures.
3. Retrieved and organized patient medical records for healthcare providers efficiently.
4. Facilitated the release of information to authorized entities in accordance with regulations.
5. Developed and maintained health record indexes and retrieval systems for effective data management.
6. Entered critical patient data into systems, including demographics and treatment history.
7. Collaborated with healthcare teams to ensure timely and accurate claims submissions.

Experience

2-5 Years

Level

Junior

Education

AAS HIT

Description :

1. Attended monthly Medicare and Medicaid training to stay updated on benefit coverage changes.
2. Provided support to clients with medical issues, facilitating communication with providers for effective resolutions.
3. Analyzed and processed professional and institutional medical claims across various lines of business.
4. Investigated pending claims, resolving issues related to contracts, fees, authorizations, and billing discrepancies.
5. Managed customer service inquiries, maintaining daily communication with members, physicians, and hospital staff.
6. Compiled and maintained patient medical records to document conditions and treatments for research and quality improvement.
7. Collaborated with cross-functional teams to enhance claims processing workflows and improve service delivery.

Experience

10+ Years

Level

Senior

Education

AAS-HIT

Description :

1. Processed and adjudicated medical claims, ensuring compliance with federal and state regulations.
2. Resolved complex claims issues, improving customer satisfaction and reducing appeals.
3. Collaborated with healthcare providers to gather necessary documentation for claims processing.
4. Maintained up-to-date knowledge of Medicare and Medicaid policies and procedures.
5. Achieved performance benchmarks in speed, accuracy, and volume of claims processed.
6. Utilized multiple medical claims software systems to manage and track claims efficiently.
7. Provided training and support to new team members, fostering a collaborative work environment.

Experience

7-10 Years

Level

Senior

Education

AAS

Description :

1. Analyzed member accounts to clarify status for members, plans, and providers, improving communication.
2. Processed refunds for member accounts, ensuring compliance with company policies.
3. Reviewed plan descriptions and DOI requirements to guarantee accurate claims adjudication.
4. Collaborated with healthcare providers to resolve discrepancies in claims submissions.
5. Maintained detailed records of claims processing activities for audit purposes.
6. Trained new staff on claims processing procedures and best practices.
7. Utilized claims processing software to enhance efficiency and accuracy in operations.

Experience

2-5 Years

Level

Executive

Education

AAS HIT

Description :

1. Authenticate and verify medical claims, ensuring all required information is complete and accurate.
2. Communicate with healthcare providers regarding claim status, eligibility, and covered benefits.
3. Maintain detailed records of claims and follow up on outstanding issues with insurance companies.
4. Interpret and apply CPT and ICD-10 codes, utilizing medical terminology for accurate claims processing.
5. Document activities in systems such as CRM, EPIC, and Cerner to track claims progress.
6. Train and supervise new claims processors during onboarding for new employer groups.
7. Analyze claims data to identify trends and recommend process improvements.

Experience

2-5 Years

Level

Junior

Education

AAS-HIT

Description :

1. Processed and adjudicated medical claims, ensuring compliance with policies and regulations.
2. Identified and resolved discrepancies in claims through thorough research and documentation review.
3. Coordinated benefits and verified ICD-10 and CPT codes for accuracy.
4. Communicated with providers to clarify claim issues and obtain necessary information.
5. Educated team members on best practices for claims processing and error prevention.
6. Managed high-dollar catastrophic claims, ensuring timely and accurate payments.
7. Utilized Prism tracking system to monitor production metrics and maintain performance standards.

Experience

2-5 Years

Level

Executive

Education

AAS HIT

Description :

1. Acted as the primary liaison for staff regarding claims processing and system utilization.
2. Analyzed performance metrics to identify areas for process improvement.
3. Executed queries to monitor claims volume and ensure timely processing.
4. Posted payments in medical claims systems, ensuring accuracy and compliance.
5. Processed diverse health insurance claims, including direct payments and reimbursements.
6. Utilized software tools to fulfill requests from members and providers efficiently.
7. Maintained up-to-date knowledge of insurance policies and procedures.

Experience

2-5 Years

Level

Executive

Education

AAS-MB

Description :

1. Entered and processed claims data accurately, interpreting medical codes and terminology for diagnoses and procedures.
2. Adjudicated claim forms, ensuring correct allocation of deductibles, co-pays, and provider reimbursements.
3. Followed established policies to guarantee proper payment of claims, maintaining compliance with insurance regulations.
4. Provided exceptional customer service to members and providers, addressing inquiries and resolving issues promptly.
5. Documented all interactions in the system, ensuring thorough follow-up on outstanding claims and inquiries.
6. Identified and resolved discrepancies in claims, enhancing overall customer satisfaction and trust.
7. Maintained up-to-date knowledge of insurance policies and procedures to ensure accurate communication with clients.

Experience

2-5 Years

Level

Executive

Education

AAS-HIT

Description :

1. Processed insurance claims by thoroughly reviewing customer policies and claim details.
2. Collaborated with health carriers and providers to resolve complex claim issues.
3. Managed claim recovery efforts, including subrogation for various insurance types.
4. Conducted phone interviews to verify the accuracy of medical claims and discuss outcomes with clients.
5. Documented claim activities and maintained professional relationships with claimants and clients.
6. Trained new medical claims processors on best practices and operational procedures.
7. Evaluated medical procedures for necessity and resolved coverage disputes effectively.

Experience

10+ Years

Level

Management

Education

A.A.S. HIT

Description :

1. Validated medical claims for accuracy and completeness, ensuring compliance with insurance policies.
2. Reviewed and corrected claims to eliminate errors, enhancing payment efficiency.
3. Maintained detailed records of claims and follow-ups, improving tracking and resolution times.
4. Processed claim forms with correct medical codes, ensuring timely payments to providers.
5. Determined patient eligibility and benefit levels, coordinating with third-party payers to resolve issues.
6. Assisted in training new staff on claims processing procedures and software usage.
7. Created and managed authorizations for medical services, verifying insurance coverage and patient demographics.

Experience

10+ Years

Level

Management

Education

AAS-MB