The Medical Claims Adjuster is a professional who is responsible for the review, investigation, and processing of medical claims. They undertake responsibility for looking into the details of the claim, negotiating settlements, and communicating with the insurance company. A well-drafted Medical Claims Adjuster Resume mentions the following core duties – reviewing and verifying medical claims, verifying insurance coverage, evaluating the claim, and negotiating settlements with the insurance company. Other core duties include investigating claims, documenting findings, and making recommendations.
Skills needed to be a successful Medical Claims Adjuster include strong attention to detail, excellent communication skills, and knowledge of medical terminology. They should also have a good understanding of medical billing and coding, medical laws, and insurance regulations. Education requirements for Medical Claims Adjusters typically include a Bachelor’s degree in a related field such as health administration, insurance, or related field. Some employers may also require certification in medical billing and coding or a related field.
Headline : Seasoned Medical Only Adjuster with 7 years of experience in managing and processing medical claims. Proficient in evaluating claims, ensuring adherence to compliance standards, and delivering exceptional client service. Committed to streamlining processes and enhancing operational effectiveness within the healthcare insurance sector.
Skills : Claims Administration, Medical Claims Processing, Claims Processing, Medical Terminology
Description :
Verified lost time, waiting periods, and wage loss calculations for accurate claims processing.
Processed daily benefits to prevent penalties and maintain compliance.
Handled medical bill payments and inquiries, ensuring timely resolutions.
Maintained comprehensive file documentation, including medical reports and case notes.
Managed medical-only workers' compensation claims, coordinating with providers and claimants.
Facilitated communication with employers to confirm claim details and prevent disputes.
Monitored claims until the injured worker reached Maximum Medical Improvement (MMI).
Experience
5-7 Years
Level
Executive
Education
B.S. in BA
Medical Only Adjuster Resume
Summary : Accomplished Medical Only Adjuster with a decade of experience in managing medical claims. Expert in conducting thorough investigations, ensuring compliance with industry regulations, and providing superior client support. Dedicated to enhancing claims processing efficiency and fostering positive relationships with all stakeholders.
Skills : Microsoft Office Suite, Customer Service, Problem Solving, Negotiation Skills, Communication Skills
Description :
Ensured compliance with established treatment guidelines for workers' compensation claims.
Recommended reserves based on comprehensive claim investigations.
Facilitated communication with insureds, claimants, and legal representatives.
Conducted detailed interviews and inspections to gather necessary claim information.
Collaborated with healthcare providers to clarify causation and manage disputes.
Oversaw timely payments of medical benefits and vendor invoices.
Maintained ongoing communication among internal teams and external stakeholders.
Experience
7-10 Years
Level
Management
Education
B.S. in Bus. Admin.
Medical Only Adjuster Resume
Objective : With over 5 years of experience as a Medical Only Adjuster, I excel in managing medical claims while ensuring compliance with industry standards. My expertise lies in conducting thorough investigations, enhancing client satisfaction, and streamlining claims processes. Driven by results, I am eager to contribute to a high-performing team dedicated to delivering exceptional service in the healthcare insurance field.
Managed all aspects of claims processing, maintaining high productivity and confidentiality.
Implemented effective management techniques to minimize loss and expense payments.
Possessed moderate authority for reserving and expensing claims.
Collaborated with the Special Investigations Unit to address potential fraud cases.
Utilized strong knowledge of medical terminology to enhance claims accuracy.
Fostered teamwork and collaboration among colleagues to improve workflow.
Operated independently within established guidelines for decision-making.
Experience
2-5 Years
Level
Executive
Education
B.S. Health Admin.
Medical Claims Adjuster Resume
Objective : Dynamic Medical Claims Adjuster with 2 years of focused experience in evaluating and processing claims. Skilled in analyzing policy coverage and ensuring compliance with industry standards. Adept at providing exceptional customer service while managing complex claim cases. Eager to contribute valuable insights and support to a dedicated team in the healthcare insurance sector.
Skills : Data Analysis, Problem Solving, Negotiation Skills, Insurance Regulations
Description :
Utilized strong analytical skills to assess complex claims and ensure accurate processing.
Communicated effectively with policyholders, attorneys, and healthcare providers to resolve claims issues.
Monitored claims for compliance with state regulations and company policies.
Developed and maintained comprehensive knowledge of healthcare insurance products and services.
Provided timely updates to stakeholders regarding claim status and outcomes.
Collaborated with team members to enhance overall claims processing efficiency.
Leveraged technology to track and manage claims, ensuring data integrity.
Experience
0-2 Years
Level
Entry Level
Education
AAS-HCA
Junior Medical Claims Adjuster
Resume
Objective : Enthusiastic Medical Claims Adjuster with 2 years of hands-on experience in evaluating and processing medical claims. Proficient in analyzing policy details and ensuring adherence to regulations. Committed to delivering outstanding customer service while effectively managing intricate claims. Ready to enhance team performance and contribute to the success of a healthcare insurance organization.
Skills : Customer Service Excellence, Risk Assessment, Conflict Resolution, Team Collaboration, Report Writing
Description :
Review and analyze medical claims for accuracy and compliance with policies.
Verified coverage by examining contracts and policy documents.
Reviewed medical documents and claims history to ensure accuracy.
Trained on client-level business rules to facilitate appropriate claims decisions.
Negotiated pricing with vendors to achieve favorable claim settlements.
Issued payments and resolved escalated claims inquiries.
Managed multiple medical claims simultaneously, addressing various issues effectively.
Experience
0-2 Years
Level
Junior
Education
B.S. Health Admin.
Medical Claims Adjuster Resume
Headline : Accomplished Medical Claims Adjuster with 7 years of extensive experience in evaluating and processing complex claims. Expert in policy analysis, compliance, and claims adjudication. Known for delivering exceptional client service while efficiently managing high-volume caseloads. Committed to enhancing operational efficiency and supporting team success within the healthcare insurance landscape.
Evaluated insurance policies and processed claims to ensure compliance with industry regulations.
Analyzed medical records and billing statements to authorize appropriate payments within coverage limits.
Collaborated with healthcare providers to resolve discrepancies and ensure accurate claims processing.
Provided expert guidance on claims procedures, enhancing departmental efficiency.
Conducted thorough investigations of complex claims to mitigate risk and prevent fraud.
Maintained detailed records of claims, ensuring accuracy and compliance throughout the process.
Utilized claims management software to streamline operations and improve reporting accuracy.
Experience
5-7 Years
Level
Senior
Education
B.S. Health Admin.
Senior Medical Claims Adjuster
Resume
Summary : Results-oriented Senior Medical Claims Adjuster with over 10 years of expertise in claims processing and adjudication. Proficient in analyzing complex policy coverage and ensuring compliance with regulatory standards. Recognized for exceptional problem-solving skills and delivering outstanding customer support while managing high-volume claims efficiently. Committed to driving operational excellence in the healthcare insurance industry.
Skills : Technical Proficiency, Case Management, Regulatory Compliance, Communication Skills, Time Management, Critical Thinking
Description :
Evaluated and processed medical claims in accordance with plan documentation and regulatory guidelines.
Conducted thorough audits to ensure compliance and accuracy in claims processing.
Interpreted complex policy documents and medical terminology to facilitate accurate claims adjudication.
Collaborated with medical professionals to clarify claim details and resolve discrepancies.
Managed high-dollar claims and prioritized tasks based on daily operational reports.
Maintained customer service logs with a turnaround time of 5 days, ensuring prompt responses.
Ensured adherence to state laws and internal policies throughout the claims process.
Experience
7-10 Years
Level
Management
Education
B.S. Health Admin.
Medical Claims Adjuster Resume
Objective : Motivated Medical Claims Adjuster with 2 years of experience in claims evaluation and processing. Proficient in policy analysis and compliance, with a strong focus on delivering exceptional service to clients. Skilled at resolving complex claims issues and enhancing operational efficiency within healthcare insurance teams.
Executed thorough coding of inpatient charts, maintaining high accuracy and efficiency.
Completed claims paperwork and documentation with precision, ensuring compliance with regulations.
Coded and billed medical claims for hospitals and outpatient facilities, optimizing reimbursement.
Conducted research on new diagnoses and procedures to enhance coding knowledge.
Identified and corrected inconsistencies in medical documentation, ensuring accuracy in claims.
Addressed provider inquiries, delivering detailed responses and support.
Reviewed outpatient medical records, analyzing diagnostic and treatment coding.
Experience
0-2 Years
Level
Entry Level
Education
AAS HIT
Associate Medical Claims Adjuster
Resume
Objective : Dedicated Medical Claims Adjuster with 2 years of experience in evaluating and processing medical claims efficiently. Expertise in analyzing insurance policies and ensuring compliance with regulations. Proven ability to deliver superior customer service while managing complex claims. Looking to leverage my skills to support a dynamic team in the healthcare insurance industry.
Skills : Policy Interpretation, Fraud Detection, Record Keeping, Billing Procedures
Description :
Processed incoming medical claims, determining client benefit coverage while ensuring adherence to Fair Claim Practice Guidelines.
Provided outstanding service to customers, effectively assessing and resolving claims associated with losses.
Conducted thorough coverage and liability investigations, applying appropriate negligence guidelines.
Reviewed necessary medical documentation to set and monitor reserves for accuracy.
Identified potential fraud indicators and subrogation opportunities throughout the claims lifecycle.
Calculated proper compensation amounts, processed claims payments, and coordinated benefits including Medicaid.
Ensure timely processing of claims to meet company standards.
Experience
0-2 Years
Level
Fresher
Education
B.S. Health Admin
Medical Claims Adjuster Resume
Summary : Detail-oriented Medical Claims Adjuster with over 5 years of experience in evaluating and processing medical claims. Proficient in analyzing medical records, verifying coverage, and ensuring compliance with regulations. Strong communication skills and a commitment to resolving claims efficiently while maintaining high customer satisfaction. Adept at collaborating with healthcare providers and insurance teams to streamline processes.
Skills : Strong Analytical Skills With Attention To Detail, Decision Making, Client Relations, Empathy, Organizational Skills, Work Ethic
Description :
Managed first-party medical claims, ensuring timely resolution and compliance.
Provided comprehensive explanations of medical insurance benefits to insured individuals and their representatives.
Reviewed and issued payments to insureds and medical providers after thorough claim investigation.
Promoted three times during tenure at State Farm Insurance for outstanding performance.
Monitored workflow quality, implementing changes to meet Service Level Agreements.
Conducted detailed reviews of medical coding, fee schedules, and reimbursement methodologies.
Collaborated with legal teams and medical professionals to facilitate complex claim resolutions.
Experience
10+ Years
Level
Senior
Education
BSHA
Assistant Medical Claims Adjuster
Resume
Objective : Proficient Medical Claims Adjuster with 2 years of experience in claim evaluation and processing. Demonstrated expertise in analyzing policy details and ensuring compliance with industry standards. Strong focus on delivering high-quality customer service while effectively managing complex claims. Eager to apply analytical skills to support a dynamic healthcare insurance team.
Skills : Icd-10 Coding, Cpt And Hcpcs Level Ii Coding, Microsoft Office Suite, Advanced Excel Skills, Presentation Skills, Claims Processing
Description :
Evaluated and adjusted medical and hospital claims for healthcare providers across multiple states, ensuring compliance with regulations.
Analyzed medical supply equipment claims for reimbursement, collaborating with suppliers for accurate processing.
Investigated suspicious claims to identify potential fraud, maintaining integrity in the claims process.
Assessed all evidence to facilitate positive outcomes for client claims, enhancing customer satisfaction.
Conducted follow-ups on flagged claims initiated by claims representatives, ensuring thorough evaluations.
Reviewed and substantiated legitimate claims, denying unjustified claims based on policy guidelines.
Maintained detailed records of all claims processed to support audits and compliance checks.
Experience
0-2 Years
Level
Fresher
Education
B.S. in HA
Medical Claims Adjuster Resume
Objective : Proficient Medical Claims Adjuster with 2 years of experience in claims evaluation and processing, specializing in policy compliance and customer service excellence. Demonstrated ability to analyze complex claims and resolve issues efficiently. Passionate about contributing to a collaborative team dedicated to enhancing the healthcare insurance experience.
Skills : Claims Analysis, Research Skills, Interpersonal Skills, Data Entry, Patient Advocacy, Insurance Policy Knowledge
Description :
Managed incoming calls, providing information and transferring to appropriate departments.
Maintained and updated claims databases to ensure accurate record-keeping.
Processed claim forms and ensured adherence to company procedures.
Created copies of essential documents for internal use.
Attached relevant files to correspondence requiring responses.
Coordinated information flow via electronic mail systems.
Distributed incoming mail and responded to routine inquiries.
Experience
0-2 Years
Level
Entry Level
Education
AAS
Medical Claims Adjuster Resume
Headline : Results-driven Medical Claims Adjuster with 7 years of comprehensive experience in processing and adjudicating complex medical claims. Specializes in policy analysis, regulatory compliance, and optimizing claims workflows. Recognized for delivering exceptional customer service and effectively managing high-volume caseloads. Dedicated to enhancing operational efficiency and fostering team success in healthcare insurance.
Skills : Customer Service, Medical Terminology, Claims Review, Medical Coding, Attention To Detail
Description :
Evaluated and processed a high volume of medical claims, ensuring compliance with industry regulations.
Conducted thorough reviews of insurance policies to verify coverage for health services.
Analyzed Medicaid claims against benefit plan designs to enhance processing efficiency.
Maintained detailed logs of all claims and communications to ensure accuracy and transparency.
Resolved customer inquiries and issues related to claims status and eligibility.
Collaborated with healthcare providers to clarify claims information and expedite processes.
Utilized data analysis to identify trends and improve claims management processes.
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