Medical Claims Specialist Resume Samples

Description :

1. Analyzed and processed medical claims, ensuring compliance with insurance policies and regulations.
2. Established proof of loss by reviewing medical documentation and coordinating with healthcare providers.
3. Maintained high-quality customer service by addressing inquiries and resolving issues promptly.
4. Collaborated with legal teams to prepare documentation for claims disputes and settlements.
5. Utilized ICD-10 coding to accurately classify diagnoses and procedures for claims processing.
6. Conducted audits of claims to identify discrepancies and implement corrective actions.
7. Developed training materials for new hires, enhancing team knowledge and performance.

Experience

10+ Years

Level

Senior

Education

BSHA

Description :

1. Managed the complete lifecycle of medical claims, ensuring accurate documentation and timely processing.
2. Reviewed and resolved claims by analyzing documentation, calculating benefits, and issuing payments or denial letters.
3. Maintained confidentiality of sensitive claims information to protect patient privacy and comply with regulations.
4. Enhanced professional knowledge by attending workshops and reading industry publications to stay updated on best practices.
5. Contributed to team goals by proactively identifying areas for process improvement and implementing effective solutions.
6. Collaborated with healthcare providers to clarify claim details and expedite resolution of discrepancies.
7. Trained new staff on claims processing protocols and software usage to ensure consistency and accuracy.

Experience

2-5 Years

Level

Junior

Education

AAS-HIT

Description :

1. Generated detailed reports to address and reverse denied claims, ensuring timely payments for services rendered.
2. Established and maintained strong relationships with medical insurance companies to facilitate claim approvals.
3. Accurately entered patient and insurance information for claims processing, ensuring data integrity.
4. Monitored and updated knowledge of third-party billing requirements and insurance changes.
5. Submitted claims and diligently followed up with insurance carriers on unpaid or rejected claims.
6. Provided training and support to new hires, enhancing team knowledge and performance.
7. Coordinated with collection agencies to manage patient accounts and resolve outstanding balances.

Experience

7-10 Years

Level

Management

Education

B.S. Health Admin.

Description :

1. Managed a portfolio of over 200 claims daily, ensuring timely resolution and compliance with regulations.
2. Communicated effectively with insurance carriers and patients to facilitate claim processing.
3. Ensured adherence to state and federal regulations while processing claims.
4. Reviewed and interpreted medical documentation, including UB04 forms and EOBs.
5. Conducted thorough analysis of claims to identify discrepancies and initiate corrections.
6. Maintained accurate records and documentation for all claims processed.
7. Collaborated with Medicare, Medicaid, and private insurers to resolve billing disputes.

Experience

2-5 Years

Level

Junior

Education

AAS

Description :

1. Specialized in examining and processing medical claims, ensuring compliance with insurance policies and regulations.
2. Possessed in-depth knowledge of CPT, ICD-10, and HCPCS codes for accurate claims submission.
3. Proactively interpreted contracts to ensure precise payment of hospital claims and conducted stop-loss calculations.
4. Collaborated with medical management for appeal processing and pre-authorization of hospital admissions and surgeries.
5. Communicated effectively with legal representatives and insurance companies regarding subrogation claims.
6. Conducted audits on claims payments, identifying discrepancies and recovering overpayments efficiently.
7. Developed and maintained the company Policy and Procedures Manual for claims processing.

Experience

7-10 Years

Level

Management

Education

BSHA

Description :

1. Prepared and submitted accurate claims to various payors, including Medicare and Medicaid, ensuring compliance with regulations.
2. Utilized electronic systems for claims submissions, including 837 electronic and CMS-1500 forms, enhancing efficiency.
3. Managed and resolved claim rejections, collaborating with internal teams to rectify issues promptly.
4. Gathered necessary information from patients and providers to address denied claims due to incorrect data.
5. Established strong relationships with healthcare providers to ensure timely billing and collections.
6. Investigated and resolved zero payment explanations, initiating adjustments to secure payments.
7. Generated and analyzed collections reports, coordinating with collection agencies for outstanding accounts.

Experience

10+ Years

Level

Senior

Education

AAS HIT

Description :

1. Processed and paid claims, determining medical codes for treatment, consistently exceeding 180 claims daily with 95% accuracy.
2. Acted as a liaison between claims and customer service departments to resolve issues.
3. Addressed inquiries regarding policy limits, claim denials, and payouts effectively.
4. Reviewed files and policy documents to assess eligibility based on provisions.
5. Entered treatment dates, medical services, and diagnoses into the claims system accurately.
6. Verified submitted invoices to ensure claim totals matched services rendered.
7. Reviewed medical records to ensure all applicable codes were submitted for maximum reimbursement.

Experience

10+ Years

Level

Senior

Education

AAS-MB

Description :

1. Review and analyze medical claims to ensure accuracy and compliance with regulations.
2. Investigate and resolve discrepancies in claims, ensuring timely processing.
3. Maintain organized electronic records of all claims and related documentation.
4. Set appropriate reserves for claims based on updated information and assessments.
5. Communicate with claimants and healthcare providers to gather necessary information.
6. Respond promptly to inquiries via phone, email, and mail, adhering to service standards.
7. Calculate and verify amounts owed for medical services, ensuring accurate billing.

Experience

7-10 Years

Level

Management

Education

AAS-MB

Description :

1. Managed the processing of 500+ medical claims weekly, ensuring compliance with insurance policies and regulations.
2. Conducted thorough follow-ups on outstanding claims, improving recovery rates by 25%.
3. Provided exceptional customer service, handling 60+ inquiries weekly from patients and providers.
4. Reviewed and processed discounts from editing services, applying them accurately to claims.
5. Performed audits on selected claims to ensure accuracy and compliance, identifying overpayments.
6. Maintained timely communication with members, providers, and insurance companies regarding claims status.
7. Trained new staff on claims processing procedures, enhancing team efficiency and performance.

Experience

5-7 Years

Level

Executive

Education

AAS-HIT

Description :

1. Review and process medical claims to determine allowable benefits and ensure compliance with regulations.
2. Evaluate services for appropriateness of charges and apply system edits as necessary.
3. Request additional information for suspended claims and initiate follow-up actions.
4. Handle provider inquiries and correspondence, addressing claim questions and concerns effectively.
5. Provide guidance to providers on Medicare guidelines, ICD-9, ICD-10, and claim submission processes.
6. Resolve provider and health plan claim inquiries promptly, ensuring high levels of satisfaction.
7. Monitor and track aged claims to maintain timely processing and reduce backlog.

Experience

2-5 Years

Level

Junior

Education

AAS-MB

Description :

1. Review and process medical claims, ensuring compliance with CPT, HCPCS, ICD-9-CM, and ICD-10-CM standards.
2. Verify accuracy of documentation and ensure all claims meet regulatory requirements.
3. Utilize electronic claims processing systems to submit and track claims efficiently.
4. Conduct audits of claims to identify discrepancies and implement corrective actions.
5. Collaborate with healthcare providers to obtain necessary information for claim submissions.
6. Resolve payment discrepancies by validating claim adjustments and communicating with payers.
7. Maintain up-to-date knowledge of industry regulations and coding updates to ensure compliance.

Experience

7-10 Years

Level

Management

Education

AAS HIT