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Medical Claims Examiner Resume Samples
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10+ years of experience
Made appropriate claim decisions based on various contracts and plan provisions. Included evaluation of claim per plan provisions, determination of eligibility, verification of data input, identification of correct benefit level, calculation of fee schedule, and performing claim corrections.
- Made outgoing phone calls to verify or obtain information regarding a claim to ensure timely processing.
- Received incoming calls from vendors, customers, brokers, groups, and providers. Successfully analyzed the caller’s needs, researched information, answered questions, and resolved issues.
- Mentored others on the team and served as a subject matter expert or contact for specific accounts.
- Verified on-line records. Maintained accurate customer information by making corrections or referred information to appropriate person to keep the customers information accurate.
- Met and exceeded the Company’s dollar quality goal of 99.5% in accurately processing claims and paying the required amount of claims per day of 115 drafts.
6-10 years of experience
Review and release medical claims for payment using CPT/ICD-9 codes; scrutinize claims for accuracy; price claims for providers with discount contracts.
- Achieved “Top Performer Awards” for 1995 and 1996, which consists of high performance and quality.
- Introduced processing idea, which was implemented throughout the corporation, saving the company $6,500 annually.
- Won the “Big Idea” award for the processing idea, which was rated 2nd out of 200.
- Earned “Special Awards” in 1994 and 1996 for consistently high production.
0-5 years of experience
Main duty was to review and pay medical claims.
- Effectively analyzed and coordinated benefits for payments on health claims.
- Processed coordination of benefit claims.
- Performed customer service to insured’s.
- Analyzed claims for possible fraud.
- Achieved and maintained quality control levels of no less than 92% monthly.
0-5 years of experience
Processed and coded medical and dental claims in accordance with benefit contract and plan policy
- Maintained the company’s production and quality standards.
- Assigned appropriate medical codes with a 95 percent accuracy rate.
- Precisely evaluated and verified benefits and eligibility.
- Investigated medical records to determine pre-existing medical conditions.
- Performed other office duties as needed
0-5 years of experience
Approved all HCFA and UB claim forms prior to payment submission. Verified that all ICD-9, CPT, modifiers and revenue codes are used correctly, prior to payment approval.
- Denied all incorrect claims submissions.
- Reviewed medical claims submitted as an appeal.
- Researched each claim and paid according to specified benefit contracts.
- Responsibility included being updated on all benefit plans for each contracted providers (121 contracts).
0-5 years of experience
Exceeded expected quota of claims processed accurately while assuring turn around within 48 hours, through utilization of TGS and PHCS programs
- Supervised the installation and testing of a new software pre-pricing system resulting in a higher level of accuracy and productivity
- Verified medical insurance coverage
- Acted as liaison with Third Party Administrators, physicians, and insured
- Processed medical claims while adjusting pricing within preferred provider group and applying specified benefits for hospitalizations
6-10 years of experience
Supervised and directed Medical Claims Associates in processing commercial claims.
- Directed department activities in claims processing to ensure adequate adjudication and improved provider satisfaction and retention.
- Identified claims cost management opportunities through internal weekly audits.
- Processed commercial medial claims for PPO, EPO, Indemnity lines of business
- Troubled shooting – researched benefits to obtain necessary documentation to process customer claims
- Answered incoming calls and resolve claims issues for High profile accounts
0-5 years of experience
Manually entered claims while interpreting coding and understanding medical terminology in relation to diagnosis’s and procedures.
- Specialized focus on Coordination of Benefits, End Stage Renal Disease, high dollar, Webstrat, CMS Pricer and complex medical claims.
- Provided expertise and general claims support by reviewing, researching, investigating, processing and adjusting claims.
- Consistently met established productivity and quality standards to guarantee timely, well organized and precise claims processing.
0-5 years of experience
Earned several monthly awards based on quality and work output.
- Promoted to Team Leader October 1998 – responsible for the management of a fifteen to twenty five person team of claims examiners.
- As a Team Leader, responsibilities included; monthly performance reviews, annual performance reviews, conducted potential employee interviews, and handled employee discipline meetings.
- Chosen to spearhead a new extension office in Beckley, WV in May 2000
- Units were consistently in the top five of the entire company, based on production and quality of work
6-10 years of experience
- Successfully processed claims for multiple insurance products, including Life, AD&D, Disability, Medical, Lost-of Time, Worker’s Compensation and Death claims
- Resolved claims through research and analysis within cost, quality and schedule requirements
- Provided customer service, including telephone, written and walk-in inquiries from participants, providers, and trustees Prepared correspondence regarding claim inquiries, including notification of claimant denials and appeal rights
- Processed voids, stop payments and refunds to adjust incorrectly processed claims
- Researched issues and documented solutions for problems
6-10 years of experience
Direct contact with customers and providers to examine and resolve claim inquires accurately and with customer satisfaction.
- Fully knowledgeable of corporate policy and the use of that policy for resolving claims disputes, making claims adjustments and authorizing payments.
- Trained in the details of the terms and conditions of various contracts, managed care programs (PPO, POS) and Medicare products.
- Working knowledge of CPT-4 and ICD-9 coding, CS90 technology, PROFS, EXCEL, Napersoft, CLMR and CRT.
- Managed and examined and adjusted surgical and medical claims via on-line systems.
0-5 years of experience
Document medical claims by completing forms, reports, logs and records
- Accurately code voluminous medical claims
- Managed staff of three claims examiners
- Originally started out as mail room supervisor and promoted within a year to claims examiner
- Trained and developed replacement for the mail room supervisor position
0-5 years of experience
Determine applicable coverage, appropriateness of charges and proper benefits for each claim based on contractual provisions, limitations, exclusions, state mandates and established company practices
- Utilize plan provisions to determine claimant & claim eligibility
- Review UB92 Hospital claim forms to assure revenue codes are appropriate for service provided
- Review HCFA 1500 claim forms for accuracy of billing based upon services provided
- Contact providers when additional information is necessary to complete claim processing and negotiate fees if applicable
- Accurately pay or deny claims based on plan & company provisions
- Communicated with policyholders, agents, providers and internal Nationwide customers via telephone and written communication
- Reviewed, research and interpreted medical records and surgical reports obtained from providers for contestability and pre-existing health history
0-5 years of experience
Reviewed and processed 150-175 claims per day to ensure accuracy of all ICD-9/CPT codes, pre-authorizations and referrals before submitting for payment
- Maintained productivity to process claims and meet payment requirements within time constraints
- Created spreadsheets for coordination of benefits claims to track payments from external agencies
- Adhered to internal procedures and policies to ensure activities are handled appropriately
0-5 years of experience
- Successfully recognized medical procedure codes and diagnosis codes to ensure accuracy
- Investigated and resolved provider and members appeals
- Reviewed medical records to determine correct processing rules
- Processed medical claims according to members health insurance, supplemental plans
6-10 years of experience
Managed Personal Insurance Protection Claims as governed by NYSID Regulations.
- Prepared injury lawsuits and appeared as expert witness for Civil Lawsuits on behalf of the company.
- Performed telephone and written communications to clients attorneys and providers for resolution and execution of claims such as maintaining a check register and bank reconciliation.
- Communicated with customers, providers and other companies to answer questions, explain coverage, negotiate settlements and manage injury claims.
- Maintained CMS Database of treatments and billing.
- Scheduled independent medical examinations and executed dispositions.
- Completed and mailed requests for NYSID forms and verifications for state compliance and handling.
6-10 years of experience
Process claim forms, adjudicates for provision of deductibles, co-pays, co-insurance maximums and provider settlements.
- Enter claims data into a AS400/Genelco system.
- Resolve member, provider and client appeals with claim payment discrepancies.
- Performed audit of randomly selected claims to ensure quality processing. Monthly audit goals are based off of Financial Accuracy, Procedural Accuracy and Payment Incident. Met on average 98%-99% of these goals and was awarded Quarterly Excellence Award for Claim accuracy.
- Researches claim overpayments and request funds.
- Follow adjudication policies and procedures to make sure proper payment of claims.
- Provide timely customer service to members’ provider, bill departments and other insurance companies on subject of claims.
- Logged telephone calls in system and followed up on outstanding issues.
0-5 years of experience
Provided claimant benefits timely and accurately
- Verified and authorized future medical treatments and medical supplies on settled cases
- Determined medical necessity of treatment including duration and frequency of such treatment
- Completed case plan entries
- Completed case documentation detailing the parties involved
- Reviewed and adjusted medical providers’ bills
0-5 years of experience
- Identified fraudulent claims and assisted in the recovery of payments
- Research and analyze medical claims via examination and coding
- Utilized knowledge of CPT-4 procedure codes, ICD-9 diagnosis codes
- Communicate with physicians and hospital personnel to validate claims
- Received Circle of Stars Award for saving the company an estimated $500.000 within the year
0-5 years of experience
- Processed all paper claims for assigned groups.
- Conducted verification of coverage per phone calls and e-mail.
- Made inbound/outbound calls to doctors and insurance offices for any additional information.
- Communicated any adjustments that were generated by aging and correspondence.
0-5 years of experience
Processed medical, dental, vision, and hospital claims utilizing ICD9 and CPT4 coding
- Provided customer service to providers, plan administrators, and members
- Handled foreign language medical and hospital claims received
- Specialized in resolution of complex claim issues
- Served as key team resource for both upper level management and peers to ensure accurate and prompt payment of medical claims
0-5 years of experience
Process Professional and Facility Claims for groups that had 20,000 or more lives
- Exceeded my daily production quota (250 claims) processing between 400 & 500 claims daily
- Request Adjustments for claims
- Backup Customer Service Representative on an inbound call line
- Quote benefits and claim status for Members and Providers
- Works off Excel spreadsheets for Reporting
0-5 years of experience
Data entry of claims ensuring accurate and timely payment to meet or exceed customer service level agreements.
- Properly adjudicate claims based on knowledge of covered benefits, insurance and provider contracts such as medical insurance on individual plans for college and K-12 students.
- Identify and resolve issues on claims according to established procedures, apply benefit coverage, and enter relevant information in order to process claims.
- Review claimant history for pre-existing issues and initiate payment or denial of claims for accident claims.
- Compile letters to request additional information in order to determine claim status while organizing claim inventory.
- Review and determine correct ICD-9 and CPT codes
- System utilized: Genelco for two months
0-5 years of experience
Researched Medicare members/beneficiary to make msp determinations
- Examined claims to be processed and verified information
- Outreached to MBR & LOB’s internal/external customers
- Reconciled and researched different databases for the purpose of making msp determinations
- Determined effect capitation & health insurance claims/billing
- Participated in high profile projects with time sensitive deadlines for the msp oci recon team which services both cms and kp nationally
0-5 years of experience
- Processed and/or denied medical claims in a rapid and accurate pace for Blue Cross of MI, Aetna, and Arizona Public Aid.
- Provided training, support, encouragement, and audit reviews to new employees on the Blue Cross Medical Records computer systems.
- Created and maintained excel spreadsheets for received, pending, and incomplete medical record requests and processed claims.
- Reported monthly audit results to vendor and management team for medical record requests and employee errors.
0-5 years of experience
Responsible for the timely processing of medical claims, including UB92 and HICFA forms
- Processing of cob, drg, and adjusted claims
- Working an aged claim report once a week
- Knowledge of medical terminology, coordination of benefits, ICD-9, CPT, and revenue codes
- Assist and back up customer service if needed
- Backup person for short term disability
0-5 years of experience
Process medical claims for payment/denial.
- Assisted with implementation of new business.
- Chosen to analyze spreadsheets for special projects.
- Created workflow organization within team.
- Produced quality work at 100%.
- Also made production within guidelines as required.
0-5 years of experience
- Answered provider and claimant calls regarding Workers Compensation
- Reviewed incoming claims for accuracy and completeness
- Filed and maintained paper or electronic records
- Processed bills on the CMS-1500 & UB-04 Forms
- Analyzed ICD-9 and ICD-10 codes for bill review
0-5 years of experience
- Verified member and patient eligibility
- Coded all medical and facility claims billed with CPT-4, DRG, Revenue, HCPCS and ICD-9 codes
- Data enter entire claim with accuracy
- Analyzed and processed erroneous claims using corporate policy submitted with CPT-4 and ICD-9 codes.
0-5 years of experience
- Review and adjudicate provider claims base on provider and health plan contractual agreement.
- Respond to resolve provider and health plan claims inquiries and apply resolution in a timely fashion.
- Maintain departmental standards on productivity and quality of work.
- Sort and prepare claims for scanning
- Data enter HCFA 1500 Claims billed charges less than $5,000.00 and UB92 less than $30,000.00 into the system for appropriate tracking and processing.
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Medical Claims Examiner
Last edited by: Gabriela Barcenas, CONTENT STRATEGIST -
Gabriela Barcenas
CONTENT STRATEGISTGabriela is a Certified Professional Resume Writer (CPRW) and career adviser. With 10 years of digital media experience and five years of resume writing expertise, her publication history includes fashion, education, travel, social justice, equitable design and career advice.
