Medical Claims Processor Resume Samples

Description :

1. Correct Authorization and Provider Network determination process to be followed as per Medicare Advantage Operations guidelines.
2. Provide Excellent Customer Service to all external and internal stakeholders Responsible for adjudicating claims which could be a new claim or a re-work on an existing claim.
3. Examiner will need to determine the correct benefit payable considering process rules and desktop procedures set-up by Medicare Advantage for the said product line.
4. Review and work applicable reports and documents pertaining to claims eligibility determination and ongoing claim benefits.
5. Responsible for timely request and follow-up request of any/all required additional information.
6. Medical records/notes, appropriate forms/documents, statements and/or certificates needed for proper claim adjudication.
7.  Respond accurately, timely and professionally to all oral and written external and/or internal correspondences received from stakeholders in regard to benefits, eligibility, claim payments, denials and/or explanation of benefits.
8. Maintain working knowledge and proficiency in company claims, administrative and imaging software systems used by Medicare Advantage.
9. Maintain client and company quality and production standards Maintain knowledge of applicable company policies and procedure.
10. Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines Interact professionally with other business units to gather and analyze data needed to properly adjudicate claims and documentation of claims files. 
11. Responsible for accurate/timely daily review of claims and policy provisions to determine appropriate claim eligibility assessments for payment or denial.

Experience

7-10 Years

Level

Executive

Education

Masters

Description :

1. Correcting electronic rejected claims and working on denied claims which sometimes involved calling insurance companies to find out why claims were denied, 
2. Determining what the best course of action would be to correct those claims if possible and sometimes sending in appeals for denied claims.
3. Speaking to patients regarding their billing questions and sometimes calling patients to obtain other information such as current insurance.
4. Contacting insurance companies to get pre-authorizations for procedures such as outpatient imaging, sleep studies & special vaccinations to be done in another facility.
5. Occasionally set up appointments for patients to see specialists, contact the patient with the information and sending referral information and medical records to the specialist.
6. Answered the phone, scheduled appointments for patients, and greeted patients at the front desk along with taking payments from patients and posting checks from insurance companies to the accounting system.
7. Responsible for accurate/timely daily review of claims and policy provisions to determine appropriate claim eligibility assessments for payment or denial.

Experience

2-5 Years

Level

Junior

Education

Accounting

Description :

1. Performed general office duties such as prepare correspondence, data entry, maintaining records, database management, open, sort, and distribute incoming correspondence to include faxes and email.
2. Accordance with HIPPA and local procedures; protect the security of medical records to ensure that confidentiality is maintained.
3. Retrieved patient medical records for physicians, technicians, or other medical personnel.
4. Released information to persons and agencies according to regulations.
5. Planned, developed, maintained and operated a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.
6. Entered data, such as demographic characteristics, history, and extent of disease, diagnostic procedures and treatment into computer.
7. Compiled and maintained patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.

Experience

2-5 Years

Level

Junior

Education

Diploma

Description :

1. Attended all monthly medicare and Medicaid classes due to monthly changes Of benefits coverages.
2. Interacting with clients with Medical issues and being able to support them to contact with affiliated providers to get them the correct medical issues solved.
3. Analyze and process professional and institutional medical claims in all lines of business.
4. Research pending claims and resolve issues regarding contracts, fees, authorizations, billing/co-pay issues, etc.
5. Responsible for keeping up-to-date on all Medicare and Medicaid procedures and diagnosis codes for medical billing.
6. Handle customer service calls and communicate daily with members, physicians, and hospital personnel.
7. Compiled and maintained patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.

Experience

10+ Years

Level

Senior

Education

Crentials

Description :

1. Handle customer inquiries, complaints, billing questions, and payment requests.
2. Locate resources for problem resolution and design best-option solutions.
3. Interface daily with internal partners in the accounting and consumer affairs divisions.
4. Resolved an average of 350 inquiries in any given week and consistently met performance benchmarks in all areas (speed, accuracy, volume).
5.  Processors and particularly challenging calls as one of the company's primary mentors/trainers of both new and established employees.
6.  Mark in all categories including communication skills, listening skills, problem resolution, and politeness.
7. Responsible for keeping up-to-date on all Medicare and Medicaid procedures and diagnosis codes for medical billing.

Experience

7-10 Years

Level

Senior

Education

Masters

Description :

1. Analyzed and presented findings on members' accounts so that account status was understood by the member, plan, and providers.
2. Investigated errors in member's accounts and worked independently to remedy the errors.
3. Remediated and educated team members when errors were identified in their processed and adjudicated claims.
4. Independently distribute payment for adjudicated high-dollar/catastrophic claims.
5. Independently issued refunds to member/employer accounts independently.
6. Researched summary plan descriptions, DOI requirements in order to assure adjudication of claims was conducted correctly.
7. Supervised other claims processors when new employer groups went live on a new/different plan.

Experience

2-5 Years

Level

Executive

Education

Diploma

Description :

1. Authenticate the information on medical claims received. and Review and make sure that there is no omitted information.
2. Make inquiries to providers on the subject of a claim, eligibility, covered benefits, denial and approval status issues.
3. Keep thorough records of claims and follow up on dropped cases with insurance companies.
4. Possess the knowledge to read claims of CPT, ICD-9 some 10 codes with more training and medical terminology.
5. Documented activities through various systems such as CRM, Citrix, EPIC, FACS, and Cerner.
6. Production tracking system called Prism and maintain production per standard.
7. Supervised other claims processors when new employer groups went live on a new/different plan.

Experience

2-5 Years

Level

Junior

Education

Diploma

Description :

1. Received claims from customer service and internally that were not processed correctly.
2. Researched these claims to find where the error had occurred by researching documents, reconfiguring payments.
3. Coordinating benefits, checking ICD-9 and CPT codes, checking claim forms for provider errors, contacting providers by phone, and contacting other state plans by phone and e-mail.
4. Investigated errors in member's accounts and worked independently to remedy the errors.
5. Remediated and educated team members when errors were identified in their processed and adjudicated claims.
6. Independently distribute payment for adjudicated high-dollar/catastrophic claims.
7. Production tracking system called Prism and maintain production per standard.

Experience

2-5 Years

Level

Executive

Education

Masters

Description :

1. Served as primary contact for staff in regard to system process and system utilization questions.
2. Performance measures to identify opportunities for staff and process improvement.
3. The operated query for assigned region checked volume and dates of claims, ensuring that all pending claims were within the acceptable processing objectives.
4. Posted payments in medical claims payment systems. and Demonstrated commitment to the client's needs.
5. Processed all types of health insurance claims including, but not limited to direct payments and reimbursements.
6. Proficient in operating all required software to complete the requests from the member or provider.
7. Provided prompt customer service to members, providers, billing departments and other insurance companies regarding claims.

Experience

2-5 Years

Level

Executive

Education

M.B.A.

Description :

1. Entered claims data into system while interpreting coding and understanding medical terminology in relation to diagnoses and procedures.
2. Processed claim forms, adjudicated for allocation of deductibles, co-pays, co-insurance maximums, and provider reimbursements.
3. Followed adjudication policies and procedures to ensure proper payment of claims.
4. Provided prompt customer service to members, providers, billing departments and other insurance companies regarding claims.
5. Documented phone calls in the system and followed up on issues if needed.
6. Resolved problems resulting from claim adjudication and customer service phone calls.
7. Proficient in making sure the information being translated to the member and the provider are accurate and up to date.

Experience

2-5 Years

Level

Executive

Education

Associate

Description :

1. Processed all insurance claims by reviewing the customer's policy in relation to the claim being made.
2. Contracted other health carriers, provider and agents to resolve claim issues.
3. Claim recovery including subrogation with auto, primary insurance, Medicare and Medicaid.
4. Made phone calls to confirm the accuracy of medical claims. and meet with customers to discuss the results of claims.
5. Commentated claim activity and processing with claimant and client relations and maintain professional relations.
6. Train new medical claims processors in all aspects of the job. and Performed clerical duties such as a file, copy fax, e-mail.
7. Approve medical procedures based on medical necessity, problem solves coverage issues.

Experience

10+ Years

Level

Management

Education

Masters

Description :

1. Responsible for validating the information on all medical claims from patients seeking payment from their insurance company.
2. Reviewed claims to ensure that there is no missing or incomplete information.
3. Kept meticulous records of claims and followed up on lapsed cases Responsible for inputting information in the system correctly with the right medical codes.
4. Codes and processes claim forms for payment ensuring all information is supplied before eligible payments are made.
5. Determined eligibility, benefit levels, coordination of benefits, and resolve third party issues
6. Receives all incoming deliveries from outside couriers.- Assists other support staff as needed; operates photocopying and fax machines.
7. Created authorizations and attached them to medical claims for payments, entered demographics and verified insurance.

Experience

10+ Years

Level

Management

Education

Diploma