jessica claire resumesampleexamplecom 555 4321000 montgomery street san francisco ca 94105 professional summary highly adaptable focused senior claims examiner 20 years experience multilevel roles managed care skilled researching complex ub04 cms1500 claims issues accurate timely resolution systematic thorough review provider contract language case rate agreements interpretation coverage plan requirements limitations additional resume information employer reviews references virtual interview viewed following link skills strong claims processing knowledge icd9 icd10 cpt4 hcpcs coding medical terminology hipaa compliance phi integrity advanced level payment threshold ub04 cms 1500 high dollar commercial medicare medicaid ppo pos dual coveragecob plan processing thorough researching interpretation complex claims system edits applying contract terms special rate negotiations manual pricing calculations dedicated interdepartmental team collaboration efficient claims resolution excellent verbal written communication skills highly experienced telecommuteremote processing vast claims processingimaging platforms ms office creating detailed spreadsheetsreports database management education richland college dallas tx web design msce track completed coursework web design msce track 19992002 northern essex community college haverhill coursework completed business management management information systems 19941997 work history unitedhealth group claims analystremote jacksonville fl 072020 current managed high volume medical claims daily basis prioritized workload based receive dates minimizing turnaround time reviewed system edits first pass professional institutional claims determine payment denial suspend areas needed ie configuration eligibility etc coordinated configuration department resolve discrepancies member benefits cost share clearinghouse issues effecting processing outcome paperedi claims focus area home health carelead examiner overseeing processing per new 2021 cms pps guidelines apply manual pricing calculations penalties uploading worksheet claim detailed audit record trained audited back examiners selected hhc focus area investigated noc hcpcs claims requiring additional documentation specialty authorization verification benefit coverage negotiated contract rates applicable tracked reviewed service request inquiries including provider member appeals customer service thoroughly documenting adjusting claim payment andor clerical errors per guidelines including overturned denials appeals developed first reference manual crosstraining examiners departments actively responsible organizing maintaining updates additions claims processing manual maintained detailed report daily basis management inventory counts penalties applied closedresolved appeals status audit results proposing identified areas additional training needs concentra claims analystadjusterremote south portland 082017 032019 processed first pass inpatientoutpatient facility professional services lines business coordination benefits cob applied plan guidelines evaluate payment denial based thorough review eligibility benefit limitations patient responsibility applicable authorization documentation requirements cob verification adjustments monetary recovery related retroactive file updates issues effecting previously processed claims assisted management generating detailed reports peer training mentoring auditing maintaining positive support feedback new hires dell financial services bpo lead claims analystadjusterremote city state 102012 062017 paid denied commercial medicare medicaid dual coveragecob inoutpatient facility professional medical claims based upon established claims processing criteria including limited provider coding supporting documentation requirements clean claim analysis accuracy completeness authorization approval services billed research manually calculated reimbursements membersubmitted foreignoutofarea nonnetwork claims applied special pricing determinations based locality medical review evaluation supporting documentation maintained database updates changes plan processing guidelines updated contract rate negotiations coding changes coordinated configuration internal departments resolve provider credentialing member eligibility discrepancies followup ownership issue claim resolved jacobson solutionstravel contract medicare enrollment specialist city state 112011 022012 handled 75 calls per day address current new enrollee inquiries regarding benefit options premiums eligibility requirements kaiser permanente health plancalifornia membership area annual open enrollment period prioritized caller needs building loyalty membership retention providing exceptional services positive caller experience recorded detailed summary outcome member interactions flagged followup needed meticulous accurate data entry enrollee information documentation upload kaiser eligibility member profile databases