Medical Claims Specialist Resume Samples

Description :

1. Determines covered medical insurance losses by studying provisions of policy or certificate.
2. Establishes proof of loss by studying medical documentation, assembling additional information as required from outside sources.
3. Documents medical claims actions by completing forms, reports, logs, and records.
4. Resolves medical claims by approving or denying documentation, calculating benefits due, initiating a payment or composing denial letter.
5. Ensures legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
6. Maintains quality customer services by following customer service practices; responding to customer inquiries.
7. Provides legal support by assembling documentation for settlement action.
8. Protects operations by keeping claims information confidential.

Experience

10+ Years

Level

Senior

Education

Certification

Description :

1. Documents medical claims actions by completing forms, reports, logs, and records.
2. Resolves medical claims by approving or denying per documentation, calculating benefits due, initiating a payment or composing denial letter.
3. Ensures legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
4. Protects operations by keeping claims information confidential.
5. Prepares reports by collecting, analyzing, and summarizing information.
6. Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations.
7. Accomplishes organization goals by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
8. Assists with the training of new hires and answer any questions they may have after training.

Experience

2-5 Years

Level

Junior

Education

HS

Description :

1. Produce and retrieve reports to reverse denied pharmacy claims, by paying for additional dollars for the FSST Clinic.
2. Establish and Maintain accounts with Medical Insurance companies to create for approval by the Pharmacist and Administration.
3. Enters information necessary for insurance claims such as patient, insurance ID, and Information.
4. Keeps updated on all third-party billing requirements and changes for insurance types within the area of responsibility.
5. Submit claims and following up with insurance carriers on unpaid or rejected claims.
6. Assists with the training of new hires and answer any questions they may have after training.
7. Maintained contact with the collection agency to update patients who have settled their accounts.

Experience

7-10 Years

Level

Management

Education

BS

Description :

1. Handled telephone calls, wrote letters, and sent faxes to insurance carriers, patients, and other responsible parties in the pursuit of getting a claim resolved.
2. Managed an extensive portfolio of claims by prioritizing and organizing time effectively.
3. Ensured legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
4. Handled and interpreted medical documentation such as UB04 claim forms and EOB's on a daily basis.
5. Analyzed documents, contracts, notes, and followed the appropriate procedures in coding and billing the claim.
6. Prepared daily notes by collecting, analyzing, and summarizing information for individual claims.
7. Cooperated with Medicare, Medicaid, and private insurance providers to resolve billing issues.
8. Worked on 40 accounts per day in a queue to meet the daily requirement.

Experience

2-5 Years

Level

Junior

Education

BS

Description :

1. Specialized in examining and processing claims for the Benefit Trust Fund with a strong familiarity with group health benefits for multiple health plans.
2. Possessed an accurate knowledge of CPT, ICD-9 and HCPS codes.
3. Demonstrated the ability to proactively interpret contracts to ensure accuracy in the payment of hospital claims and performed stop loss calculations.
4. Interfaced well with medical management for appeal processing issues and special cases as well as pre-authorization for hospital admissions and surgeries.
5. Communicated with lawyers and auto insurance companies regarding motor vehicle accidents and subrogation claims.
6. Audited files regarding incorrect claims payments, overpayments and handled the recovery of all monies.
7. Compiled claims plan provisions in order to prepare and maintain the company Policy and Procedures Manual.

Experience

7-10 Years

Level

Management

Education

Certification

Description :

1. Prepared and generated clean claims for submission to all payor types, including third-party payors, Medicare and Medicaid.
2. Submissions of claims to be are done via 837 electronic, CMS-1500, fax, and online web portal.
3. Facilitated all rejections from electronic or paper claims.
4. Obtained information from carriers, stores, internal entities or patients when services billed are denied for reasons such as incorrect insurance information, demographic information and/or authorization.
5. Developed and maintained working relationships with internal/external providers to ensure billings and collections procedures were current.
6. Researched and resolved all zero payment explanations or benefits and exercises all options to obtain claims payments; initiated adjustments as necessary.
7. Ran collections reports, uploaded accounts and sent to a collection agency.

Experience

10+ Years

Level

Senior

Education

ABA

Description :

1. Paid Claims, determined medical codes for treatment, frequently exceeding the required 180 claims per day quota with 95% or higher accuracy.
2. Provided internal Customer Service (liaison between the claims and customer service departments).
3. Answered questions regarding policy limits, claim denial or payout.
4. Reviewed files, policy information and other documents to determine eligibility based on policy provisions.
5. Entered data such as treatment date, medical services, and diagnoses into the system.
6. Verified charges on submitted invoices to ensure claim totals match for services rendered.
7. Reviewed medical records as necessary to ensure all possible medical codes have been given for maximum payout.
8. Processed difficult, large sum or complex claims including high priority and cancer claims.

Experience

10+ Years

Level

Senior

Education

Diploma

Description :

1. Review files to determine the current status of injury claims and develops a plan of action for future handling.
2. Investigates claims to determine the medical relevance of the treatment provided.
3. Ensures that all documents pertaining to a claim are electronically attached and labeled correctly in the claims management system.
4. Determines proper reserves are set on files and makes appropriate changes as new information is received.
5. Maintains contact with the claimant or their legal representative to determine the current status of treatment.
6. Responds to all voicemail, mail, and faxes in accordance with the accountability standards.
7. Calculate figures and amounts such as discounts, interest, commissions, and percentages for claimants' medical bills, loss wages, and possible prescription reimbursement.

Experience

7-10 Years

Level

Management

Education

BS

Description :

1. Organized incoming mail daily by opening, sorting, and stamping with day's date then distributed mail to the correct department or person.
2. Followed up on claims where the refund was needed by calling the provider to discuss the claim or sent a refund letter to the appropriate party.
3. Processed 50 to 1000 claims weekly by organizing by insurance plan and then entered claim by procedures that were set in place.
4. Provided excellent customer service to customers and providers either in person or over phone, about 45 to 60 calls week.
5. Processed discounts that were received from editing service and applied to correct claims daily.
6. Performed audit of randomly selected claims to ensure quality processing researches claim overpayment and request funds.
7. Followed timely customer service to members, providers billing departments and insurance companies on the subject of claims.

Experience

5-7 Years

Level

Executive

Education

Associate

Description :

1. Review all medical claims inquires and apply processing rules to determine allowable benefits for payment.
2. Review services for appropriateness of charges billed and consider system edits.
3. Suspend claims requiring additional information and/or special handling, initiates action to obtain information.
4. Service calls and correspondence from providers, Identifies and/or responds to claim inquires, enrollment questions and dissatisfactions.
5. Assist providers with reference material to obtain knowledge on Medicare guidelines, ICD-9, ICD-10, and general claim submission.
6. Responds to and resolves provider and health plan claim inquires.
7. Monitors and tracks aged, pended and open reports to maintain timeliness in claims processing.

Experience

2-5 Years

Level

Junior

Education

HS

Description :

1. Examine vouchers, invoices, claims and other payment requests for medical services for authorized patients.
2. Documents must be accurate, provide adequate documentation or citations, and comply with laws and regulations.
3. Justification submitted must be in compliance with CPT, HCPCS and ICD-9-CM and ICD-10-CM standards.
4. Possess knowledge of electronic claims editing and submission capabilities, including on-line claims processing and query systems.
5. Ensure appropriate diagnostic and procedural coding for all HCFA-1500, UB92 and other claim forms.
6. Validate appropriate claim adjustments to resolve payment discrepancies.
7. Worked with various off-site facilities to obtain missing patient information needed to submit claims.

Experience

7-10 Years

Level

Management

Education

HS