Medical Claims Examiner and support specialist in which the day to day tasks included but were not limited to: handling cases and processing medical claims, correspondence with Clients and large Insurance carriers on a daily basis.
- Medical Claims Examiner at FirstSource
- Billings Specialist / Collection Agent at Diversified Consultants, Inc
- Team Lead at IBM SPOC - Flextronics / Aerotek
- Customer Service Specialist at Geek Squad City
3 months at this Job
Well organized and self-directed individual, with exceptional administrative and interpersonal skills acquired through many years of working in high volume environments, seeking to apply my knowledge and abilities in a professional atmosphere. Medical Claims Examiner-First Source
January 2016 to Present
• Review health-related claims to see if the costs are reasonable based on the diagnosis
• Reviews plan documents that provide information on requirements and regulations
• Authorizes appropriate payment, denies claims or refer claims to investigators for more thorough review
• Records daily production using Production Reporting System
• Knowledge of ICD-9, IDC-10, CPT Coding, HIPAA Regulations
• Knowledge of PC applications and systems
• Ability to read an interpret general business correspondence, procedure manuals
• Excellent keyboarding skills.
• Ability to work in team environment and fluctuating workloads.
- Medical Claims Examiner-First Source at Yes
- Cashier at Publix
- Customer Service Specialist at Plato's Closet
- Office Assistant at Dr. Scott Perrino
3 years, 2 months at this Job
• Performing complex audits of electronic claims for payment integrity in alignment with regulatory strand timelines, business policy’s, appropriate coding and system configuration
• maintain current knowledge of all change regulatory requirements within Medicare and medical.
• Evaluate problems and errors in work with appropriate staff to resolve them.
• Knowledge of medical coding, RVS, CPT, ICD-9, ICD-10 and HCPCS
• Understanding of medical claim forms: CMS 1500, UB-04
• Knowledge of Encoder Pro And crystal report
• Knowledge of HIPAA compliance rules and policies
• Manual calculations of procedures not adjudicated by claims system
• Record information on claim files such as copayments and deductibles; updating and/or correcting to insure accuracy
- Medical Claims Examiner at Independence Medical Group
- Claims Adjuster at CRDN
- Caregiver at Visiting Angels
- Independence medical group at
1 year at this Job
- Diploma - Medical billing and coding
• Research and adjust medical claims for overpayment, underpayment and analyze refunds according to contracting rates (DRG, APG) fee schedules, and authorizations guidelines.
• Review, claim suspensions from the system to correct daily and monthly reports edits to ensure accurate claims reimbursements.
• Produces management reports relative to inventory productivity and accuracy.
• Assisting examiners with inquiries regarding claims discrepancies, and their responsibilities. Medical Claims Examiner:
• Responsible for data entry and front end review of claims with the use of accurate procedure and diagnosis codes (CPT, ICD-9/10) under the correct providers and member benefits for the Medicaid lines of business.
• Adjudicate and coordinate benefits with Medicare and other insurances carriers' claims concerning Deductibles, Co-pay and Co-insurance balances.
- Assistant System Analyst / Senior Medical Claims Examiner at Metro Plus Health Plan-NYC-HHC-Health and Hospitals Corporation
- Senior Medical Claims Examiner at AFTRA
- Senior Medical Claims Examiner at Local 1199 Home Care Benefit Fund
- Temp at Health Insurance Plan of Greater NY
4 years at this Job
• Research and process claims in accordance with the MEBA Plan
• Create and maintain Case Management files, communicating directly with Case Managers.
• Prepare and submit monthly Stop Loss reports to Stop Loss carrier. Communicate directly with Stop Loss Carrier.
• Utilization Review: review claims without preauthorization for medical necessity, to determine whether it needs retro review; prepare and submit for retro review.
• Prepare appealed claims for Medical Review.
• Research pended claims
• Respond to emails sent by CareFirst that include approvals for adjustment requests, and/or clarification of how claims were processed for their provider inquiries.
• Review and determine appropriate action for any items referred by the Member Services Department that require claims processing knowledge.
• Process Pensioner Life Benefit Claims
• Process MEBA Diagnostic Center travel reimbursement claims
• Conduct research into current medical policy
• Assist Medical Dept Manager in preparing Standard Operations Manual
- Senior Medical Claims Examiner at MEBA Benefits Plans
- Substitute Teacher; Teacher Assistant Special Education at Anne Arundel County Public Schools
- ESOL Tutor at Baltimore County Public Schools
- Medical Claims Processor at MEBA Benefit Plans
6 years, 2 months at this Job
- BS - Sociology
• Actively handle and investigate fraudulent medical claims
• Make appropriate recommendations to SIU for further investigations
• Aid in investigations by running social media checks
• Have helped in the training classroom with new hires to PIP department
- MEDICAL CLAIMS EXAMINER at GEICO
- MANAGEMENT TRAINEE at HERTZ
- SUBSTITUTE TEACHER at WEST ISLIP UFSD
4 years, 1 month at this Job
- BACHELORS - English
91709 Angelo Escalante, Staffing Manager: (714) 986-5548 Examined and processed basic medical claims for appropriateness of care and completeness of information in accordance with accepted coverage guidelines, ensuring all mandated government and state regulations were consistently met. Approved pending or denied payments according to the accepted coverage guidelines. Maintained internal customer relations by interacting with staff regarding claims issues researched, and ensured accurate and complete claim information.
- Medical Claims Examiner at Amtec Human Capital
- Tech at Zone Solutions
- Medical Claims Processor at Cognizant Technology Solutions
- Claims Specialist II at Corporate Job Bank
1 year at this Job
• Researches patient eligibility and claims history
• Determines accurate provider reimbursement based on VA Choice program guidelines
• Applies knowledge of business rules to properly adjudicate medical claims
• Exports paid claims invoices to VA clearinghouses for reimbursement
• Regularly exceeds production and quality assurance goals
- Medical Claims Examiner I at Kelly Services
- Caregiver at In-Home Supportive Services
1 year, 4 months at this Job
- - Certified Medical Administrative Assistant
- High School Diploma
Analyze medical and dental claims for Federal Virginia employees. Enter data and figures on claims and obtained 100 quality accuracy for 2018. Assist other employees with questions and order supplies for the team.
- Medical Claims Examiner at Anthem, Inc.
- PROGRAM COORDINATOR/ RECEPTIONIST at RESCUE MISSION MINISTRIES
- Internship Student working with Veteran Reintegration Program and VA Cares Re-entry Program at Total Action for Hope
- RECEPTIONIST at VIRGINIA WESTERN COMMUNITY COLLEGE
2 years, 3 months at this Job
- Associates of Applied Sciences - Human Services
Examine claims for unions members. Make any corrections that is needed to process the claim quicker. Request any medical records to verify treatment and to allow the union groups to process payments within a certain time frame.
- Medical Claims Examiner at Blue Cross Blue Shield of IL, MT, NM, OK & TX
- Customer Service at Connecticut life
1 month at this Job
- BBA - Business Administration
- - Certified Nursing Assistant