Claims Auditor Resume Samples

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Claims Auditors check the validity and accuracy of policyholder claims, thus ensuring the profitability of insurance companies. Essential work activities listed on a Claims Auditor example resume are applying auditing standards, checking the correctness of claims, approving or denying claims, and justifying their decisions. Based on our collection of Claims Auditor resumes, main job requirements are knowledge of claim auditing procedures, accuracy, confidentiality, decision-making, computer competences, and effective communication. Most candidates have a four-year college degree in auditing, accounting, or finance.

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1

Healthcare Claims Auditor

  • Identified and invoiced over $1.5 million of overpaid medical claims in first half of 2017
  • Exceeded production goals while maintaining quality
  • Secured sensitive data in compliance with HIPAA regulations
  • Contributed to the Successful Auditing initiative in May 2017
  • Mentored new and struggling team members
Candidate Info
5
years in
workforce
2
years
at this job
BS
Business
2

Claims Auditor

  • Audited paid healthcare claims to determine if overpayment exists
  • Analyzed data and reviewed provider contracts to identify claim payment errors
  • Precisely completed appropriate claims paperwork, documentation, and system entry
  • Assisted manager with training of new employees and offered assistance to coworkers with questions
  • Evaluated all evidence with the ultimate goal of creating positive outcomes for client's claims
  • Produced highest amount in recoveries with lowest void rates compared to coworkers of same position
Candidate Info
9
years in
workforce
3
years
at this job
BS
Psychology
3

Claims Auditor

Process incoming driver's logs per vendors regarding daily trips per patient's medical appts.

  • Answer phones and email per patients and vendors regarding reimbursement
  • Print drivers logs for daily review for in order to approve trips taken for reimbursement
  • Reprocess reimbursement checks and clear through management, if needed
  • Mail out reimbursement checks to vendors and or patients as needed
  • Verify mileage via MapQuest and verify reimbursement checks were deposited via Oracle
Candidate Info
9
months in
workforce
9
months
at this job
HS
Medical Insurance
4

Reimbursement Representative/ Claims Auditor

  • Collections on outpatient dialysis claims, make follow up calls with insurance companies, negotiate with the proper reimbursement on unpaid and underpaid claims. Knowledge of UB04 and 1500 claim forms.
  • Work with Management to track trends, improve processes, and quality of data to facilitate process improvements and minimize denials and reductions in reimbursement
  • Reviewed/analyzed billing and denial data to identify areas of opportunity.
  • Adjust claims as needed, applied the Six-Sigma Process excellence methodology to Billed Hospital Claims and Professional claims.
  • Work Discrepancy Report to determine types of discrepancies and assign appropriate reason
  • Experienced with all payers including Medicare, Examine UB and 1500 claims for accuracy and correct codes for correct reimbursement.
  • Reviewed and followed up audit suspense reports to ensure all pending claims met departmental turnaround time. Worked with worker's compensation and TPL claims.
Candidate Info
11
years in
workforce
4
months
at this job
MA
Marketing
5

Claims Auditor

Assisted in development and implementation of credit card payment.

  • Audit automobile and motorcycle mechanical repair claims per insurance contract guidelines.
  • Assist dealership personnel in reconciling claims payable accounts and review claim payment explanations.
  • Maintain a 100+ audit per shift level
Candidate Info
16
years in
workforce
1
year
at this job
6

Claims Auditor

  • Auditing reimbursement claims for Flexible Spending Accounts that are sent in by participants.
  • Coding of the Claims to get them ready for keying into the computer
  • Entering the Claims into the database, getting them prepared for payment
Candidate Info
11
years in
workforce
4
years
at this job
HS
High School Diploma
7

Specific Claims Auditor

  • Review and interpret employer plans of health coverage and excess insurance policy to individual claims.
  • Audit submitted claim documents for sufficient data, verify that benefits were paid correctly and in accordance with appropriate plans and policies, and determine liability
  • Communicates in writing and verbally with TPA/client as needed to resolve claim processing issues.
  • Set claims reserves and adjusts as needed. Keep the reserves current.
  • Authorize checks for amount of liability and communicate to TPA/client reasons for any amounts not covered by excess policy.
  • Refer large dollar claims and trigger diagnosis to preliminary claims and case management departments
Candidate Info
9
years in
workforce
2
years
at this job
AS
Associate of Science
BA
Bachelor of Arts
8

Claims Auditor

  • Successfully mastered the adjudication of medical claims through the QNXT system
  • Worked as part of a team to maintain and decrease claims inventory prior to major transition to QNXT system.
  • Worked as part of a team to reduce backlogged adjustment volume subsequent to transition to QNXT system.
  • Communicates and works effectively within a team and individually to complete various special projects within set time lines.
  • Maintains the highest level of privacy.
  • Proactively communicates with other departments to ensure cross-functional concerns are identified and addressed.
  • Works collaboratively with all internal and external customers.
  • Identify opportunities to enhance plan policies and align with cost containments initiatives.
Candidate Info
15
years in
workforce
8
years
at this job
Certification
9

Quality Claims Auditor

  • Accurately perform a minimum of 120 daily quality audits for Medicare and Medicaid claims processed by claims examiners and performs high dollar audits on claims billed over $100K weekly while working with minimal supervision.
  • Identifies processing, system and/or operational issues in order to ensure claims are paid according to provider contracts and CMS guidelines and current ICD-10/CPT coding.
  • Provides problem analysis and strategies for resolution and/or implementation to Management
  • Identify error trends requiring training and enhance quality within the company in order to provide stable performance to Providers, as well as recommend process improvement to ensure all quality and accuracy goals are met for multiple business units being supported by QA team.
Candidate Info
14
years in
workforce
4
years
at this job
HS
High School Diploma
Certification
10

Claims Auditor Reimbursement Integrity

  • Utilizing CMS, Commercial payer, or available Milliman guidelines to review many types of claims including inpatient/ outpatient hospital, medical, surgical, neonatal, and transplant for accurate adjudication.
  • Review and correct UB 04 inpatient and outpatient billing and coding errors when appropriate especially in regards to all the new biological drug treatments.
  • Regular communication with clients and insurance provider representatives coordinating efforts to identify variance trends and causes. Working with auditors across projects to consult on clinical matters.
Candidate Info
23
years in
workforce
3
years
at this job
BSN
Bachelor of Science in Nursing
Adn

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