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Skillful Claims Analyst resume

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Professional Summary

Highly skilled and effective Healthcare Professional with over 13 years in the healthcare industry. Solid billing formularies knowledge and significant experience working in hospitals, insurance and medical office environments. Skilled in managing front office functions, including customer service, patient appointments, billing and collections, and records management. Seeking a position in health administration in order to bring a proven track record of conflict resolution and customer care to a dynamic team.


  • Efficient medical documentation auditing for code appropriateness and guidelines
  • Skilled in preparing patients' chart, including coding and billing
  • Outstanding aptitude working in a team environment and handling responsibilities


  • Proficient in Microsoft Office Products, Nasco: AS400 Systems
  • Extensive knowledge of ICD-9, CPT codes, HCPCS, and pharmaceutical coding
  • Strong organizational, multi-tasking and problem solving skills
Work History
Claims Analyst, 06/2004 to Current
Horizon Blue Cross And Blue Shield Newark, NJ
  • Perform qualitative analysis of records to ensure accuracy, internal consistency and correlation of recorded data
  • Interact with providers and other medical professionals to administer timely customer service regarding billing and documentation policies, procedures and regulations in a high volume center
  • Meticulously identify and rectify inconsistencies, deficiencies and discrepancies in medical documentation with suggested resolution to appropriate departments
  • Investigate and resolve member/provider disputes of inaccurate claims information and payment by written correspondence and exceeding the company's turn around time
  • Follow adjudication policies and procedures to ensure proper payment of claims
  • Examine patients' insurance coverage, deductibles, possible insurance carrier payments and remaining balances not covered under their policies when applicable
  • Mentor and assist 15 new team members with questions and issues
Nursing Unit Coordinator, 05/2002 to 05/2012
Saint Barnabas Medical Center Livingston, NJ
  • Reviewed, analyzed, and maintained coding of diagnostic and treatment procedures contained in outpatient and inpatient medical records
  • Professionally and courteously verified patient's tests and appointment times
  • Communicated with doctors, registered nurses, patients as well as other departments to relay all needs and pharmaceutical concerns
  • Adeptly maintained medical charts and/or electronic medical records (filing, Op Reports, test results, home care forms)
  • Handled over 90 in house and outside phone calls on a daily basis from providers as well as patient's family members in regards to medical staff and ordering treatment for patients as per HIPAA guidelines
Billing Specialist, 11/1999 to 05/2002
Skytel Communications Wayne, NJ
  • Assisted customers on corporate accounts with maintenance needs such as programming issues regarding pagers on major accounts
  • Researched and resolved billing and invoicing problems
  • Sold new products and services resulting in increased revenues by 15% within the first year
  • Verified details of transactions including funds received and total account balances

Associate of Applied Science: Current
Union County College - Cranford, NJ

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Job-winning Claims Analyst resume

This resume is created in 7 minutes.
Professional Summary
Seeking a position in healthcare where I can utilize my claims processing skills and insurance knowledge to help patients and clients better understand their insurance benefits.
  • Bilingual in English and Spanish
  • Microsoft Office Suite Programs proficiency
  • Lotus Notes
  • Records management professional
  • Excellent problem solver
  • Medical billing / coding and claims processing (HCPC, CPT, REV CODES, HCFAs, UBs and ICD 9 and 10)
  • CPR / BLS Certified
  • Basic pharmacology knowledge
  • Research and data analysis
  • Resourceful and reliable worker
  • Adept multi-tasker
  • Comprehensive knowledge of medical office procedures and requirements (HIPAA / OSHA / CLIIA)
Work History
02/2016 to 04/2017
Insurance Claims Specialist Allstates Medicaid Milford, MA
  • Provided customers with courteous, friendly, fast and efficient service.
  • Contacted patients to schedule medication deliveries and verify correct address information.
  • Contacted insurance companies to determine status of claims investigation and coverage eligibility.
  • Corrected and resubmitted rejected Third Party claims according to individual insurance plan requirements to receive payment in an efficient manner.
  • Assisted patients with the enrollment process for manufacturer and non-profit organization funded copay assistance programs.
03/2013 to 08/2014
Health Claims Analyst International Union Operating Engineers - Local 4 Medway, MA
  • 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.
04/2006 to 07/2010
Provider & Pricing Team Lead / Customer Service Representati Health Plans, Inc / Harvard Pilgrim Health Care Westborough, MA
  • 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.
High School Diploma:
Joseph P. Keefe Technical High School - Framingham, MA
  • Emphasis in Business Technology, Office Procedures and Accounting

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Experienced Claims Analyst resume

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  • Strong presentation skills
  • Experienced managing projects
  • Knowledgeable in Microsoft Excel, Word, Outlook
  • Ability to define problems, collect data, establish fact, draw valid conclusions
  • Excellent Interpersonal, communication, writing skills
  • Resourceful, committed, driven team player
  • Strong customer service skills
  • Ability to read and  interpret extensive variety of documents
Work History
Hospital Claims Analysts Bottom Line Systems - Crescent springs, KY 10/2014 - Current
  • Identified contractual issues that contributed to 3.2 million in client underpayment.
  • Reviewed insurance contracts to gain a better understanding of payment methodologies that led to underpayment.
  • Prepared and submitted correspondence such as letters, appeals, and inquiries.
  • Defined contractual issues that led to underpayment.
  • Prepared reports that identified underpayment and payment methodology.
  • Built strong, lasting relationships with clients, payers and co workers.
Substitute Teacher Professional Educational Group - Burton, MI 09/2007 - 10/2014
  • 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.
Provider Relations Coordinator SelectCare Inc. - Troy , MI 05/1991 - 05/1997
  • 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


Provider Relations Representative Connecticut General Life Insurance Company - Southfield, MI 08/1988 - 01/1991
  • Developed a national network of mental health providers.
  • Managed contract negotiations for 17 states.
  • Educated providers on managed care contract.
  • Engaged in contract resolution.
Claims Analyst Connecticut Life Insurance Company - Southfield, MI 07/1986 - 08/1988
  • Accurately processed medical claims.
  • Positively engaged in problem resolution with providers and enrollees.
  • Prepared correspondences to providers and enrollees.
Bachelor of Science: Health Administration Eastern Michigan University - Ypsilanti, MI
Associate of Arts: Liberal Arts Macomb Community College - Warren, MI
30 credit hours toward Master of Science in Business Administration