Medical Claims Examiner Resume Samples

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Medical Claims Examiners are in charge for following insurance procedures and submitting claims. Other duties of these employees are verifying claims, checking if treatments and procedures are based on the patient’s condition, and eventually authorizing or denying the claim. Based on our collection of resume samples, the ideal candidate should demonstrate medical claims expertise, accuracy, impartiality, attention to details, time management, organization, and computer competences. Successful resumes make display of a certificate in medical billing.

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1

Medical Claims Examiner/senior Claims Examiner

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.
Candidate Info
22
years in
workforce
22
years
at this job
Medical Secretary
2

Senior Medical Claims Examiner

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.
Candidate Info
6
years in
workforce
6
years
at this job
HS
High School Diploma
C
Certificate
3

Medical Claims Examiner

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.
Candidate Info
2
years in
workforce
2
years
at this job
HS
Medical Terminology
4

Medical Claims Examiner III

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
Candidate Info
3
years in
workforce
3
years
at this job
GED
GED
Property And Casualty Claims Adjusting
5

Medical Claims Examiner

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).
Candidate Info
2
years in
workforce
2
years
at this job
AAS
Applied Science
6

Medical Claims Examiner

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
Candidate Info
3
years in
workforce
9
months
at this job
7

Supervisor-medical Claims Examiner

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
Candidate Info
7
years in
workforce
7
years
at this job
Insurance / Wausau Insurance
8

Medical Claims Examiner

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.
Candidate Info
14
years in
workforce
3
years
at this job
9

Medical Claims Examiner

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
Candidate Info
2
years in
workforce
2
years
at this job
BBA
Accounting
10

Medical Claims Examiner

  • 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
Candidate Info
13
years in
workforce
10
years
at this job
BS
Computer Engineering

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