A Claims Benefit Specialist works for the human resources team and is responsible for overseeing the company’s claims benefit systems, creating benefits packages that attract potential employees. The daily and core activities associated to the post are listed on the Claims Benefit Specialist Resume as – coordinating retirement, pension, and stock ownership plans; researching and analyzing healthcare plans; designing a comprehensive benefits package to meet the needs of a changing workforce; evaluating the costs and benefits of wellness programs, and employee assistance programs; evaluating job positions for classification, status and salary requirements; planning and evaluating techniques for compensation employees; advising management on resolving benefits issues, and reviewing vendor invoices, and resolving disputes.
Typical attributes for this role include – excellent written and verbal communication skills, strong interpersonal skills; the ability to think rationally and analytically; general business knowledge, and a strong foundation in human resources. Those thriving to make a career in this line should possess at least a degree in human resources management or its relevance.
Headline : Experienced medical and dental claims processor from start to finish. Diligent and responsible wireless and landline customer service specialist experienced in customer communication and resolution of customer issues involving service quality, billing, and service plan details.
Skills : Customer Service Experience, Administrative Skills, Multitasking.
Description :
Processed claims accurately and timely in Aetna's systems utilizing Aetna policy guidelines and in accordance with key performance measures and first touch resolution.
Researched and resolved claim payment related issues involving member specific information.
Achieved and maintained all phases of the Aetna Value Wheel as it pertains to integrity to always do the right thing for the right reasons, caring for others by listening and being respectful and compassionate, be excellence by delivering the highest quality and value possible in everything that we do and inspiration to inspire each other to make the world a better place.
Passed monthly status and financial audits by receiving 100 percent.
Utilized multiple systems to obtain and record claim information.
Posted data to adjudicate claim payment.
Assisted in achieving team and department goals in quality and turnaround time.
Experience
5-7 Years
Level
Executive
Education
High School Diploma
Claims Benefit Specialist Resume
Objective : To obtain a Claims Benefit Specialist position where my knowledge and skills can be utilized in a progressive environment with room for manager or supervisor position. To Gain Medical, Health Experience in a medical environment.
Skills : Microsoft Word, Assisting Skills, Multitasking, Problem Solving Skills.
Description :
Reviewed claims working off project list or work queue.
Responsible for providing expertise or general support in reviewing, researching.
Experienced in a production-based environment with an emphasis on quality outcomes.
Reviewed and adjudicated medical claims in accordance with CMS claim processing guidelines.
Accurately processed claims billed on UB04 Claim forms and HCFA claims forms.
Maintained/met compliance time-frames.
Responsible for editing and adjudicating claims.
Experience
2-5 Years
Level
Executive
Education
High School Diploma
Claims Benefit Specialist Resume
Objective : Claims Benefit Specialist with 2 years of experience in Monitoring, researching and resolving collection of outstanding premium overdue accounts or revenue adjustment issues.
Skills : Customer Service Experience, Accounting, Coordinating Skills.
Description :
Assisted the coach (assistant manager) when needed which includes assigning work to other processors and assuring that tasks have been completed.
Acted in a supervisory capacity when called upon including making supervisor call-backs and assisting client company executives.
Analyzed and approved routine claims that cannot be auto adjudicated.
Applied medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
Coordinated responses for routine phone inquiries and written correspondence related to claim processing issues.
Reviewed electronic claims for accuracy of billing components.
Supported documents per State laws and policies.
Experience
2-5 Years
Level
Executive
Education
High School Diploma
Claims Benefit Specialist Resume
Objective : Reliable and friendly analyst who quickly learns and masters new concepts and skills. Passionate about helping customers and creating a satisfying experience. Seeks a position of increased responsibility and authority. Detail-oriented, organized and extensively trained in spreadsheets, transcription, word processing, power point and desktop publishing.
Skills : Microsoft Excel, Interpersonal Skills, Problem Solving Skills.
Description :
Processed medical claims in regards to plans purchased through the Health Insurance Marketplace.
Performed data entry of claims into an electronic claiming system.
Entered, recorded, and tracked data entry claims.
Processed medical claims in accordance with individual plan benefits.
Processed inpatient and outpatient hospital claims.
Interacted with management on workload, issues and backlog Made outbound calls to members and providers in regards to benefits and customer service.
Exceeded quality and financial goals on claims processing.
Experience
2-5 Years
Level
Executive
Education
High School Diploma
Claims Benefit Specialist Resume
Summary : Seeking a Claims Benefit Specialist position with an outstanding career opportunity that will offer a rewarding work environment along with a winning team that will fully utilize management skills.
Skills : Driven Professional With Extensive Experience In Healthcare, Developing Skills.
Description :
Responsible for the resolution of escalated customer service issues.
Researched claims to determine company liability.
Reviewed records, identified fraudulent claims.
Audited department works, and provided feedback for process improvement.
Researched and responded to appeals from customers, in compliance with state legislation.
Collected overpayments made to customers.
Made adjustments to claims processed incorrectly.
Experience
7-10 Years
Level
Management
Education
GED
Claims Benefit Specialist Resume
Summary : Hardworking, organized, Claims Benefit Specialist professional with a proven background delivering sensible claiming solutions on time and under budget while working as a team member or team leader.
Skills : Microsoft Office, Maintenance Skills, Analyzing Skills.
Description :
Analyzed claim data for accuracy to determine the next step in the payment process.
Approved medical claims for payment and forwarded it to the correct insurance provider.
Provided information to payers and members regarding claim status, Paid Dailey invoices and met the end of month quotas, assisted in entering employee payroll hours.
Maintained employee payroll Handled customer complaints, resolving all issues in a timely manner.
Assessed the quality of in-bound calls for home emergencies.
Maintained client relations to keep costs to customers at a minimum level.
Accessed information utilizing multiple systems, Image Viewer, and other programs to complete tasks.
Experience
10+ Years
Level
Senior
Education
GED
Claims Benefit Specialist Resume
Headline : Multifaceted, efficient and reliable administrative professional with more than ten of experience supporting executives, claims managers and supervisors to improve internal operations. Proficient in all standard office software and web design programs, plus ACAS. Service-oriented and diversified skill sets covering administrative support, client relations, customer service, account management, training company personnel, planning and organizing projects.
Skills : MS Office, Data Entry, Coordinating Skills.
Description :
Experienced processing Stateside, Medicaid, and Medicare medical/hospital claims.
Applied medical necessity guidelines as appropriate to decision claims.
Determined coverage eligibility verification prior to processing claims.
Identified discrepancies and applies all cost containment measures.
Managed and routed paper claim submissions to meet appropriate contracted turnaround times.
Provided benefit information to customers.
Researched and processed COB (Coordination of Benefit) claims.
Experience
5-7 Years
Level
Executive
Education
GED
Claims Benefit Specialist Resume
Objective : As a Claims Benefit Specialist, responsible for Reviewing and adjudicating routine claims in accordance with claim processing guidelines, etc.
Skills : Microsoft Office, Burgess Reimbursement System, AS400 Warehousing Software, CPT, Medicare, Medical Billing, Medical Coding.
Description :
Processed Medicare insurance claims for members and medical providers.
Utilized various computer programs such as Microsoft Excel, Outlook, RUMBA, and Burgess Reimbursement System to price and organize claim volume.
Mentored customer service representatives and new employees on claims processing guidelines.
Granted override access to claims requiring further investigation and special handling.
Worked in compliance with HIPPA regulations and Government standards.
Assigned to special projects that require immediate attention and have to be completed within a specific timeframe or deadline.
Consistently met quality bonus requirements for both accuracy and volume.
Experience
2-5 Years
Level
Executive
Education
Bachelors Of Science
Claims Benefit Specialist Resume
Objective : As a Claims Benefit Specialist, responsible for Documenting all calls and communicating customer needs to the applicable claims personnel; followed up and completed work that originated from calls received, etc.
Set up, managed, reconciled, processed, and/or balanced bank and/or customer accounts.
Managed delinquent accounts through resolution.
Monitored, researched, and resolved a collection of outstanding premium overdue accounts or revenue adjustment issues.
Ensured that premium/fee remittances are posted accurately across various benefits and account structures and reconcile customer remittances.
Completed a benefits investigation on all received referrals to ensure a patient has valid coverage prior to transferring the patient record to the dispensing specialty pharmacy partner.
Make outreach to PBM to verify benefits and/or resolve rejected claims.
Obtained the necessary information needed to obtain successful adjudication.
Experience
2-5 Years
Level
Executive
Education
G.E.D
Claims Benefit Specialist Resume
Objective : As a Claims Benefit Specialist, responsible for Entering, retrieving, editing and revising corporate database to ensure that information is accurate, up to date, and reflects the current status, etc.
Skills : Medical Terminology, Electronic Medical Records, Communication Skills.
Description :
Analyzed and approved routine claims that cannot be auto adjudicated -Apply guidelines, resolve eligibility issues, and identify and resolve discrepancies to complete the claim adjudication process, processing patient claims, and PBM/VSP invoices.
Handled reimbursement claims to Medicaid.
Analyzed claims to ensure accurate billing and payment.
Routed and triaged complex claims to Senior Claim Benefits Specialist. Proofed claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements.
Facilitated training when considered a topic subject matter expert. In accordance with prescribed operational guidelines, manages claims on the desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor).
Utilized all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools).
Processed claims for Fortune 500 companies such as BP, 7/11, Costco, American Airlines, and Conoco utilizing ACAS and Aetna intranet systems.
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