Insurance Reimbursement Specialist Resume Samples

Description :

1. Determined program eligibility.
2. Verified patient benefits for all assigned patients within program-required timeframes.
3. Facilitated prior authorization process within the required timeframes.
4. Communicated patient responsibility timely and accurately.
5. Assessed and refered appropriately for special programs when available.
6. Acted as a single point of contact for an assigned group of prescribers.
7. Effective and timely communication with prior authorization and/or patient enrollment status.
8. Completed accurate entry of billing information to ensure timely payment and avoid delay in inpatient therapy.
9. Communicated with payers for claim rejection resolution.

Experience

10+ Years

Level

Senior

Education

BS In Management Information Systems

Description :

1. Conducted benefits investigation, verify insurance benefits, on behalf of patient and Physicians' office, and submit and obtain prior authorization as required by the payer.
2. Accurately entered data in all required fields of the client database.
3. Effectively utilize the client database to monitor outstanding items on each client case file.
4. Ensured that all patient files are maintained and inclusive of all communications as well as medical and other documentation associated with each working case, allowing any other team member to clearly see what steps have been completed and determine current status.
5. Participated in conference calls with Client Service Representative, Client Management, and Physicians' Offices regarding the status of the case, drug orders, and status of alternative funding.
6. Participated in Call Center Activities, which entails triaging incoming calls from patients, insurance companies, physicians, sales representatives, pharmacies, and home care representatives.
7. Responsible for good housekeeping techniques, adhering to quality and production standards while complying with all applicable company, state, and federal safety environmental programs and procedures.

Experience

2-5 Years

Level

Junior

Education

Diploma

Description :

1. Actively participated in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
2. Undered general supervision, is responsible for processing insurance and billing insurance in a timely manner.
3. Reviewed assigned electronic claims and submission reports.
4. Resolved and resubmited rejected claims appropriately as necessary.
5. Processed daily and special reports, unlisted invoices, and letters, error logs, stalled reports, and aging.
6. Performed outgoing calls to Patients and Insurance companies to obtain necessary information for accurate billing.
7. Answered incoming calls from Insurance companies requesting additional information and/or checking the status of billings.
8. Adhered to all company policies and procedures.
9. Adhered to the Hospital Corporate Compliance Plan and to all rules and regulations of all applicable local, state, and federal agencies and accrediting bodies.

Experience

7-10 Years

Level

Management

Education

Diploma

Description :

1. Maintained work queue daily to ensure timely follow-up. 
2. Researched account specifics in order to follow up appropriately.
3. A/R followed-up and insurance reimbursement to research account specifics and complete necessary follow-up actions, contact insurance payers on aged/.
4. Knowledged of all facets of insurance claims filing, requirements, and regulations.
5. Maintained complete and accurate follow-up on appeal and denial actions in the daily work tool system to ensure timely follow-up.
6. Became a Certified Revenue Cycle Representative through the Healthcare Financial Management Association.
7. Contacted commercial insurance carriers and assist patients with appeals and grievances for carriers to pay hospital visits.
8. Liaised with the Department of Banking and Insurance regarding scheduling arbitrations for delinquent accounts.

Experience

5-7 Years

Level

Executive

Education

Certificate In Medical

Description :

1. Provided extensive account review of underpaid facility claims for resolution by phone, fax, and online within a quick and efficient manner.
2. Contacted insurance carrier to take appropriate action to resolve obstacles with prompt payment and account review.
3. Assisted coworkers and new hire employees with complex account questions and additional training.
4. Demonstrated knowledge of medical terminology; ICD-9, HCPCS, and CPT codes; knowledged of Medicare and Medicaid, as well as Commercial payer's rules and regulations in accordance with HIPAA guidelines and collection and legal issues and billing guidelines.
5. Handled incoming calls and correspondence from patients and insurance companies.
6. Showed ability to work independently or within a group to isolate and identify trends as well as solve problems.
7. Successfully passed the CRCR within the first week of employment.

Experience

2-5 Years

Level

Junior

Education

BBM In Business Management

Description :

1. Reviewed collection accounts for both contracted and non-contracted providers in compliance with state and federal statutes as assigned.
2. Communicated with payers to discuss timely and accurate claim processing.
3. Investigated patient accounts and compose appeals to submit to payers for facilities and on behalf of the patient.
4. Collaborated with peers to provide and present observations regarding payer's policies and practices.
5. Obtained Certified Revue Cycle Representative Certification.
6. Exceeded production standards Positive collaboration with peers to assist with investigating trends.
7. Resolved high-dollar accounts for payment.

Experience

5-7 Years

Level

Executive

Education

Diploma

Description :

1. Obtained insurance benefits; which include provider Tax ID, NPI, patient Membership ID, effective date, co-payments, deductible, coinsurance, out-of-pocket maximum, lifetime maximum.
2. CPT, HCPCS, and Diagnosis codes presented to the insurance agent on behalf of multi-specialty medical provider offices across the nation; thereby obtaining approval for a small surgical procedure performed in an outpatient office setting for the drug Testopel.
3. Completed benefit investigation summary for all Commercial, Medicare, Medicaid, and Military coverage.
4. Prior authorization, Pre-determination, Referrals, Medical Policy details are summarized and in some cases, our team offers assistance if requested by the provider or health care professional.
5. Courtesy calls made to providers' offices to obtain missing information or handwritten illegibility clarity on enrollment forms submitted electronically.
6. Entered information in the eHUB system for an electronic record of recorded call center conversations representing United BioSource - Express Scripts drug Testopel.
7. Data entry work training received thereby achieving cross-training that enhanced the reimbursement process for closed cases.

Experience

2-5 Years

Level

Junior

Education

CPT In Medical Terminology

Description :

1. Responsible for a southwest territory covering 8 states.
2. Provided support and work directly with the regional sales team, patients, providers, and all payers to secure proper application of patient plan benefits and the highest level of reimbursement.
3. Contractual liability coding reimbursement and policy analysis of all-payer types.
4. Denial management, G&A, reconciliation of accounts.
5. Successfully worked with Medicare auditor to secure and obtain DME certification.
6. Resolved a 1.4 million dollar outstanding claim/billing issue with Anthem and recovered 74% of billable dollars.
7. Prepared and reviewed claims to ensure billing accuracy according to payer requirements including codes, modifiers, pricing, dates, and authorizations.

Experience

2-5 Years

Level

Junior

Education

Healthcare Administration

Description :

1. Performed and processed accurate billing procedures using analytical skills to resolve debit and credit balances on accounts while ensuring expeditious payments.
2. Evaluated and secured all appropriate financial information to maximize reimbursement, while demonstrating proficiency in billing.
3. Resolved complex payer issues to completion on a daily basis within the guidelines of Federal and State regulations.
4. Completed 50-100 accounts effectively and efficiently.
5. Consistently met and exceeded goals put before me.
6. Maintained a positive relationship with surrounding departments internally and externally.
7. Provided support to several different hospital locations by handling their billing, collections and refunds.
8. Billed out claims for the hospitals to the insurance companies.
9. Collected on current and past-due claims from the insurance companies.

Experience

5-7 Years

Level

Executive

Education

Associate Of Arts In General Education

Description :

1. Verified insurance eligibility and provide accurate information.
2. Obtained patient coinsurance and deductible responsibility detail pertaining to procedures.
3. Performed related work as required, including pre-authorizations, pre-certifications, and eligibility.
4. Attended required meetings Comply with policies and procedures.
5. Followed HIPPA guidelines.
6. Responsible for contacting the insurance carrier specific to the assigned account queue and following up on the underpaid claims to result in payment on the account.
7. Reviewed account specifics to evaluate how to follow-up with the Insurance payer on the aged or delayed claims, and be responsible for contacting them to move the account forward in the payment process.
8. Filed clinical or 'good-faith' appeals and seek retro-authorizations when necessary.

Experience

2-5 Years

Level

Junior

Education

HS In General Studies