Medical Claims Adjuster Resume Samples

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.

Medical Claims Adjuster Resume example

Medical Claims Adjuster Resume

Summary : As a Medical Claims Adjuster, Knowledge of healthcare insurance policy concepts including in network, out of network providers, deductible, coinsurance, co-pay, out of pocket, maximum inside limits and exclusions, state variations.

Skills : Audit, Excel, Customer Service, Supervisor.

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Description :

  • Possessesed special strengths in customer service, analysis and problem solving.
  • Demonstrated sound critical judgment, and decision-making skills.
  • Focused on results and providing the best overall customer experience.
  • Developed and maintained a solid working knowledge of the healthcare insurance industry and of all products, services and processes performed by the team.
  • Experienced in working with and managing professionals.
  • Provided professional and positive customer service to policyholders, claimants, attorneys, physicians and the general public.
  • Determined policy coverage, medical necessity and appropriate charges for complex Personal Injury Protection (PIP) and Med Pay claims.
  • Years of Experience
    Experience
    10+ Years
    Experience Level
    Level
    Management
    Education
    Education
    Bachelor's In Insurance


    Medical Claims Adjuster Resume

    Summary : To obtain a challenging and rewarding Medical Claims Adjuster position in a professional workplace. To leverage 8+ years of customer finance, decision making skills, and customer service experience into a role with growth potential.

    Skills : Dedicated to Providing Excellent Care To Patients.

    Medical Claims Adjuster Resume Format
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    Description :

    1. Investigated and processed insurance claims filed by vendors and members.
    2. Verified coverage by examining contracts.
    3. Reviewed medical documents, policy documents, policy history, Claims history, and system notes.
    4. Trained client-level business rules to make appropriate Claims decisions, call out claims trends, and flag fraud activities.
    5. Negotiated with vendors pricing to settle claims.
    6. Issued payments and answer escalated claims calls.
    7. Responsible for managing and evaluating various insured's medical claims simultaneously; meanwhile, solving various claims problem on the insured's.
    Years of Experience
    Experience
    7-10 Years
    Experience Level
    Level
    Senior
    Education
    Education
    BBA


    Medical Claims Adjuster Resume

    Objective : Self-motivated and technically skilled administrative, accounts receivable and insurance claims professional with sound knowledge in administrative functions, client relations, policy interpretation, contracts, collections practices and developing payment solutions.

    Skills : Customer Service, EKG.

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    Description :

  • Analyzed policies/contracts and reviewed applications to determine proper policy coverage and benefit eligibility.
  • Reviewed, researched medical bills and records to authorize and make accurate payments within coverage limits.
  • Consistently provided excellent customer service.
  • Followed best claim practices and specific state laws to properly process claims.
  • Operated in partnership with liability, underwriting and special investigations in the acquisition and preservation of undesirable risks.
  • Communicated and sent correspondence to policyholders, claimants, attorneys and healthcare providers.
  • Assisted in the training and development of new claims adjusters.
  • Years of Experience
    Experience
    2-5 Years
    Experience Level
    Level
    Junior
    Education
    Education
    BBA

    Medical Claims Adjuster Resume

    Summary : Seeking a Medical Claims Adjuster position where I can apply work experience with an organization that is committed to helping the community and provides personal development and potential for career growth.

    Skills : Expert in Microsoft Office Programs, Bloomberg Proficiency, Fluent with SPSS, Excellent interpersonal.

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    Description :

  • Examined, processed, calculated and adjudicate claims in compliance to plan documentation.
  • Processed any open audits daily.
  • Interpreted and applied provisions of manuals, SPD, medical terminology and insurance claims.
  • Checked Cigna/TC3/Claimsguard daily and process any associated claims.
  • Followed daily direction to process high dollar claims and other priorities/issues listed on the daily report that are distributed twice daily.
  • Maintained customer services logs within a 5 day turnaround time and maintain HR logs within a 2 day turnaround time.
  • Complied with state laws, policy, company procedures, and plan documentation.
  • Entered codes, and verify data for computer processing.
  • Met or exceeded daily claim production goals.
  • Years of Experience
    Experience
    10+ Years
    Experience Level
    Level
    Executive
    Education
    Education
    Bachelor Of Science

    Medical Claims Adjuster Resume

    Summary : Medical Claims Adjuster, directly communicated with our Members, Local Unions, Provided & PPO networks on the telephone or through email while working closely with Management Staff in a team-oriented atmosphere to solve claims processing issues.

    Skills : Pre-authorization, Work Comp, Employee Benefits.

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    Description :

  • Coded inpatient charts at a rate of number per hour or number per day.
  • Precisely completed appropriate claims paperwork, documentation and system entry.
  • Correctly coded and billed medical claims for various hospital, Ambulatory Units and Doctor's facilities.
  • Researched newly identified diagnoses and/or medical procedures to expand skills and knowledge.
  • Meticulously identified and rectified inconsistencies, deficiencies and discrepancies in medical documentation.
  • Researched questions and concerns from providers and provided detailed responses.
  • Reviewed, analyzed and managed coding of diagnostic and treatment procedures contained in outpatient medical records.
  • Years of Experience
    Experience
    10+ Years
    Experience Level
    Level
    Management
    Education
    Education
    Bachelor's in Insurance

    Junior Medical Claims Adjuster Resume

    Objective : Versatile Medical Claims Adjuster offering experience in medical, insurance, customer relations and other business related fields. Analyzed medical claims to determine accurate and appropriate compensations Consulted with medical professionals to assess potential fraud.

    Skills : Logistics, Insurance, Claims Processing.

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    Description :

  • Attended to incoming medical claims, and determine client benefit coverage while adhering to company's best practices, Fair Claim Practice Guidelines, while ensuring regulatory compliance and the proper administration of medical benefits to injured workers.
  • Consistently provided excellent service to all customers, and assess and resolve claims associated with losses.
  • Completed, thorough coverage and liability investigations, and assess/apply the appropriate negligence guidelines to the involved parties.
  • Obtained and reviewed necessary medical documentation in order to set appropriate reserves and subsequently monitor them for accuracy.
  • Conducted investigations and identify potential fraud indicators and subrogation opportunities throughout the life of claim files.
  • Determined proper compensation amounts, prepare check run activity, process payments for claims, coordinate the cutting of checks, manage subrogation, and the coordination of benefits including Medicaid and Medicare.
  • Maintained an active, organized caseload, and prepare status reports for management audit and analysis.
  • Years of Experience
    Experience
    2-5 Years
    Experience Level
    Level
    Junior
    Education
    Education
    Bachelor's in Insurance

    Senior Medical Claims Adjuster Resume

    Summary : Hardworking, dedicated employee with 12+ years of Medical Claims Adjuster experience. Organized and diligent, with excellent written, oral and interpersonal communication skills. Strong work ethic and positive attitude. Skilled at learning and applying new information. Able to work independently with little to no supervision.

    Skills : Self motivated with excellent interpersonal and communication skills.

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    Description :

  • Responsible for handling first party medical claims.
  • Answered multi line phones, explained medical insurance benefits to Insureds, contacted attorneys and medical providers.
  • Issued payment to Insured and medical providers after review, Investigated facts of accident and medical care.
  • Received 3 promotions while employed by State Farm Insurance.
  • Monitored quality when needed make changes to the the work flow to ensure we would meed the daily Service Level Agreement.
  • Reviewed for eligibility of claim; process and adjust if necessary.
  • Reviewed medical coding, fee schedules and reimbursement methodologies.
  • Years of Experience
    Experience
    10+ Years
    Experience Level
    Level
    Senior
    Education
    Education
    High School Diploma

    Associate Medical Claims Adjuster Resume

    Objective : As a Medical Claims Adjuster, Substantiated legitimate claims and denied unjustified claims. Evaluated insurance policies and analyzed damages to determine coverage.

    Skills : ICD-9, HCPCS and CPT coding, Medical Terminology,Microsoft Word, Excel, PowerPoint, and Access.

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    Description :

  • Examined and adjusted medical and hospital claim/bills for Doctors in the Philadelphia, PA, New Jersey, and Out of state emergency care Doctors.
  • Examined and adjusted Medical Supply Equipment claims for reimbursement to the insured and to the medical supply providers.
  • Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
  • Evaluated all evidence with the ultimate goal of creating positive outcomes for client's claims.
  • Followed up on potentially fraudulent claims initiated by claims representatives.
  • Investigated claims involving potential and suspected fraudulent activities.
  • Substantiated legitimate claims and denied unjustified claims.
  • Years of Experience
    Experience
    2-5 Years
    Experience Level
    Level
    Junior
    Education
    Education
    MBA

    Assistant Medical Claims Adjuster Resume

    Objective : Significant experience in personal injury insurance claims processing. Superior communicator and motivated self-starter. Effectively manage demanding case load and high-priority projects with exemplary customer service.

    Skills : Tax Consulting, Auditing, Management, Customer Service, Creative Thinking, Investigative Techniques.

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    Description :

  • Answered telephones and give information to callers, take messages, or transfer calls to appropriate individuals.
  • Created, maintained, and entered information into databases.
  • Completed forms in accordance with company procedures.
  • Made copies of correspondence or other printed material.
  • Located and attached appropriate files to incoming correspondence requiring replies.
  • Operated electronic mail systems and coordinate the flow of information, internally or with other organizations.
  • Opened, readed, routed, and distributed incoming mail or other materials and answer routine letters.
  • Years of Experience
    Experience
    2-5 Years
    Experience Level
    Level
    Junior
    Education
    Education
    AAS

    Medical Claims Adjuster Resume

    Objective : To obtain a career-oriented growth position within the Human Resources Profession that can best utilize my education, drive, superior analytical and interpersonal skills along with my work experience in the Health Care and Insurance Industry. Reviewed medical coding, fee schedules and reimbursement methodologies.

    Skills : Proficient in Microsoft Word, Excel, PowerPoint, Outlook, Microsoft Works.

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    Description :

  • Received medical claims that needed to be financially adjusted allowing me to work in a production environment, at times, under pressure.
  • Processed and researched medical/dental claims, paid Flex Spending Account claims, clerical duties.
  • Reviewed, researched and analyzed Medicaid claims according to benefit plan designs, analyze work load and methods to efficiently process claims.
  • Reviewed insurance policies to determine coverage for health insurance.
  • Maintained telephone logs of all incoming/outgoing calls and all processed claims.
  • Resolved status calls/Customer service related issues.
  • Reviewed for eligibility of claim; process and adjust if necessary.
  • Years of Experience
    Experience
    2-5 Years
    Experience Level
    Level
    Junior
    Education
    Education
    B.S.