Claims Analyst resume examples

• Electronically processed medical claims from Blue Cross Blue Shield of Massachusetts.
• Resolved provider inquiries relating to billing and payment patiently and efficiently.
• Clarified medical, dental, prescription, and vision benefit information for members.
• Maintained provider databases using Microsoft Excel and other accounting software platforms.
• Researched and adjudicated claims that were not able to be auto-adjudicated based on complexity.

• Contributed to superior customer service by processing claims efficiently and effectively in response to provider, client, and group member requests.
  
• Ensured electronic databases were up-to-date with the most current provider information.
• Maintained current knowledge of provider billing procedures and contracts for accurate pricing and payment.
• Exported data from our intranet into Excel format to submit to external partners for claims pricing.
  
• Provided assistance settling claim pricing errors and omissions using research and problem solving skills.

• Developed lesson plans and presented material in an effective, professional, and coherent style.
• Applied appropriate teaching strategies in the classroom with various skill levels.
• Ability to lead and interact positively with co-workers and parents.
• Prepared reports and collect data as needed.

• Managed contract negotiations between hospital, physicians, and ancillary providers.
• Educated providers on health care products.
• Conducted meetings and presentations on newly developed product.
• Took on leadership role to provide accurate client payment

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• Developed a national network of mental health providers.
• Managed contract negotiations for 17 states.
• Educated providers on managed care contract.
• Engaged in contract resolution.

• Accurately processed medical claims.
• Positively engaged in problem resolution with providers and enrollees.
• Prepared correspondences to providers and enrollees.

• Assisted in development of Risk Management processes and procedures
• Ensured all insurance claims were entered into the risk database in a timely manner.
• Prepared OSHA logs on all accidents on and off ramp
• Prepared monthly KPI's to provide a detailed break down of all workers compensation related injuries.
• Worked closely with insurance brokers to ensure all insurance certificates and coverage were up to date for all business units.
• Maintained and updated an asset database.

• Followed checklists to verify that all important parts were examined.
• Communicated with customers regarding vehicle issues and potential repairs.
• Maintained a 90% customer service satisfaction rating.
• Organized work records and filed reports.
• Reviewed the work of 6 auto mechanics.

• Provided customer service for an average of 50 calls per day, answering customer inquiries, solving problems, and providing new product information.
• Answered questions regarding company and products, while maintaining knowledge of current sales and store promotions.
• Guaranteed positive customer experiences and resolved all customer complaints.
• Directed calls to appropriate individuals and departments.

• Resolved an average of 7 technical inquiries each day.
• Programmed and troubleshot devices following installation.
• Calibrated and monitored devices following installation.
• Recommended system-level hardware and software installations.

• Reviewed and analyzed suspicious and potentially fraudulentcredit cardclaims.
• Evaluated all evidence with the ultimate goal of creating positive outcomes for client\'s claims.
• Substantiated legitimate claims and denied unjustified claims.
• Followed up on potentially fraudulent claims initiated by claims representatives.
• Collaborated with the claims department and industry anti-fraud organizations to resolve claims.
• Created new processes and systems for increasing customer service satisfaction.
• Answered an average of60 claimsper day by addressing customer inquiries, solving problems and providing new product information.

• Customer Service
• Sales Expertise
• Mortgage Industry Standards
• Maintained current loan and pricing information on the online banking website.
• Recommended loan approvals and denials based on customer loan application reviews.
• Maintained friendly and professional customer interactions.

• Managed a portfolio of250 accounts totaling $500,000 in sales.
• Effectively led a seasoned team of partner managers and account coordinators.
• Oversaw sales forecasting, goal setting and performance reporting for all accounts.
• Collaborated with other account managers to prepare and deliver performance updates and quarterly business reviews.
• Wrote sales contracts for orders obtained and submitted orders for processing.
• Prioritized daily workflows, including all inbound calls, quotes and sales-related inquiries.
• Exceptional Interpersonal Skills
• Customer Inquiries
• Customer Needs
• Team Player
• Outbound Telephone Marketing
• New Customers
• Inbound Calls
• Specific Products
• Dedicated Team Player

• Adhered to all federal and state compliance guidelines relative to retail mortgage lending.
• Provided expert financial advice on mortgage and both educational and personal loans.
• Recommended loan approvals and denials based on customer loan application reviews.
• Assisted senior-level credit officers with complex loan applications.
• Originated, reviewed, processed, closed and administered customer loan proposals.
• Compiled database of loan applicants\' credit histories, corporate financial statements and other financial information.
• Performed daily maintenance of the loan applicant database.
• Developed and maintained relationships with local real estate agents.
• Analyzed applicants\' financial status, credit and property evaluation to determine feasibility of granting loan.
• Submitted loan applications to the underwriter for verification and recommendations.
• Determined appropriate rate locks, issuance of disclosures, overage and underage waivers and fee waivers.
• Educated customers on the variety of loan products and available credit options.
• Reviewed and edited loan agreements to ensure accuracy.
• Executed the loan origination process, including ordering credit reports, appraisals and preliminary title reports.
• Researched insurance information and flood certificates.

• Provide Superior Customer Service to providers.
• Answer and/or return all incoming calls within 4 hours to providers and customer service inquiries.
• Provide by mail, fax or email copies of EOR's to provider when necessary.
• Ensure proper follow-up and customer communication when appropriate.
• Prescreen claims for the purpose of applying preauthorization of rules according to ODG guidelines.
• Prepare Claims for entry, applying the proper denial code for no preauthorization.
• PLN, PEER, RME, DDE, IRO and other report entry into system annotation history for all client claims.

• Utilized adjuster knowledge by assisting and providing clerical and administrative support to a group of Worker's Compensation Case Managers.
• Accurately set up new requests for medical services from providers in order to treat the injured employee via EDI, utilizing knowledge of medical and insurance terminology, ICD-9, and CPT 4 codes.
• Managed incoming calls from medical providers, legal staff, and claimants in reference to the injured employee.
• Customer Service duties demonstrated while taking incoming and making out going calls. 

• Medical Bill Review Clerical Support Team Lead / Medical Prescreen.
• Managed prescreening for the purpose of applying preauthorization of rules according to ODG guidelines.
• Managed the SFI (scan file index) functions to ensure that the appropriate Quality Assurance (QA) was being provided.
• Established and maintained relationships with all clerical staff to ensure knowledge of their accounts, process and workflows from all levels.
• Assisted with annotations, interface of medical claims with Medical Bill Review.
• Managed employees and worked with management to proactively evaluate staffing needs.
• Oversight of performance reviews, training and relationship building.

• Re-priced and reported savings on claims for contracted insurance participating with ACS PPO networks.
• Processed payments from insurance to send to participating providers.
• Quality assurance on claims to ensure they were sent out clean also on payments to ensure providers were paid correctly.
• Answered incoming calls from providers that wanted to check status of claims that were re-priced and billed on their behalf.

• Performed data entry of provider generated HCFA 1500 and UB 92 hospital bills.
• Audited company generated Explanation of Benefits for accuracy of ICD-9 CPT 4 and HCPCS codes.
• Made contact with providers for missing billing information per company protocol.
• Performed special assignments related to claims processing/bill review as directed by supervisor or team lead.

• Performed data entry of provider generated HCFA 1500 and UB 92 hospital bills4.
• Audited company generated Explanation of Benefits for accuracy of ICD 9, CPT 4 and HCPCS codes.
• Made contact with providers for missing information per company protocol.
• Performed data entry duties of claims form from KFI/OCR (key from image/optical critical repair) data base.
• Performed scan room duties of placing provider claims forms into KFI/OCR database by way of Kodak scan equipment.
• Performed mail room duties of company generated information to providers and clients notifying of status of submitted claims.
• Performed back up duties of processing incoming claims for the purpose of preparing claims to be coded and data entered into database.
• Performed back up customer service duties receiving and making calls to providers and clients.

• Answered incoming calls from plan participants regarding pre-authorization of medical procedures and admissions as outlined by healthcare carrier.
• Made outbound calls to healthcare facilities verifying dates of discharge.
• When guided through by company software and criteria, authorized office visits and surgical procedures for plan participants.
• Audited incoming provider claims with the purpose to ensure prior authorization was given from carrier to provider for specific procedures and medical equipment according to Texas Workers Compensation rule 134.600.
• Prepared incoming claims for data entry staff by batching and labeling claims.
• Performed back up data entry duties of overflow claims as directed by supervisor or team lead utilizing the Texas Workers Compensation fee schedule.