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Claims Processor Resume

SKILLS: MS Excel, MS Word,Access, Accounts Receivable, Balance Sheet, Office Procedures, Basic Anatomy/Physiology, BMR Claims, Collections/Billing, Customer Service, Ca - Citrix/, Data entry, DME, Emdeon, Era,Edi ICD9 & CPT Coding, Isuite, Lotus 1,2,3, MDX Media.com, Medi-Cal, Medical Terminology, Medicare/ CMS, Medisoft,, EPIC/ Z-CAP, Oracle PPO/ HMO, SIS/ Confidential, Macess/ Facets, Cisco WebEx, Cisco AnyConnect, RSA Token

EMPLOYMENT:

Confidential

Claims Processor

Responsibilities:

  • Price and develop/ Audit - Veteran Administration (VA) claims for missing information in accordance with VA regulations and guidelines.
  • Analyze claims to be determine if all claims filing requirements have been met.
  • Update line items to complete adjudication of claims.
  • Analyze claims to determine Pricing and claim filing requirements are met and make determinations.
  • Maintain integrity of claim auditing system by identifying and reporting potential system problems.
  • Provide examples and documentation to support findings.
  • Initiate written communication via web application letter writing system.
  • Troubleshooting claims with potential third-party liability, and stop loss claims / potential stop loss files.
  • Approving, Pending, or Pricing according to the accepted coverage guidelines.
  • Perform data entry into Claims management software and other Microsoft applications-(Access, Excel)

Confidential

Claims Processor

Responsibilities:

  • Analyze, Audit, pay/review and adjudicate health insurance claims.
  • Process claims for inpatient, outpatient facility and professional services, Workers compensation, Behavioral Health, Etc.
  • Verify member eligibility, benefit coverage and researching or applying authorizations
  • Review and approve the claims/pay.
  • Perform data entry, verifying client information, processing credit reports and financial documentation
  • Obtain and authorization signatures on necessary documents
  • Review supporting documentation for approval process and payments
  • Perform research, data entry, process and or adjust health care claims using a variety of healthcare related systems
  • Strong understanding of benefits and healthcare terminology.
  • Encounter both standard and non - standard Medical Claims
  • Verifying patient account, authorization information; analyze the information to determine payment amount or denial of payment.
  • . Examine claims and calculate reimbursement based on contract terms to determine accuracy of payment along with supporting documentation.
  • . Handled 115-180 accounts per day

Confidential, Fountain Valley, CA

Patient Account Representative

Responsibilities:

  • Processes health insurance claims and medical payments for clients. Assists in the client appeals process.
  • Identifies, researches, resolves claim issues, and requests for additional documentation where needed.
  • Ensures payment processing timeliness and accuracy are met.
  • Creates and updates financial batch records for processing by accounting.
  • Obtaining, verifying and documenting all claim and insurance benefit information
  • Submitting accurate/clean claims to insurance carriers for payment, including coordinating benefits with multiple insurance carriers and protecting benefits from with any pending third - party claims.
  • Reviewing claim payments for proper reimbursements; appealing underpaid or denied claims
  • . Examine claims and calculate reimbursement based on contract terms to determine accuracy of payment through use of various reports and supporting documentation.
  • Reviews and Reconcile outstanding claims and/or unpaid accounts
  • Posts, processes, reviews, and reconciles denials for insurance claims
  • Follow up with providers and insurances for missing claims information
  • Strong customer service Skills committed to meet/exceed customer needs
  • . Strong knowledge of managed care and hospital patient accounts

Environment: Medicare/ CMS, Medisoft, EPIC/ EZ-CAP, Edi, Oracle PPO/ HMO, SIS, Power Mhs

Confidential

Patient Accounts Healthcare Representative

Responsibilities:

  • Analyze HCFA and UB - 04 claims and adjudicate according to Benefit Plan/Guidelines.
  • Review/Audit, process claims, Resolution of complex and high dollar claims.
  • Calculate benefits due within a designated authority level.
  • Process claims for inpatient, outpatient facility and professional services, Workers compensation, Behavioral Health, Etc.
  • Resolved a high volume of claims edits for all lines of business.
  • Thorough understanding of authorizations, benefits, contracts, enrollment and fee schedules.
  • Hospital Collection, Commercial, Government, Managed Care
  • Handled 80-120 accounts per day

Environment: Medicare/ CMS, Medisoft, EZ-CAP, Edi, Oracle PPO/ HMO, Xcelys , SIS,

Confidential, San Dimas, CA

Reimbursement Healthcare Representative

Responsibilities:

  • Handled account follow - up/collections on hospital accounts such as Gardena Memorial Hospital, St. Francis Medical Center, St. Vincent Medical Center, Downey Medical Center, etc.
  • Followed-up on accounts from current to 80 days.
  • Performed Audits of Claims Processed by the Claims Department & employees' batches.
  • Accounts Receivable / Post Recovery Checks into Claims Data Base for
  • Tracking & Reporting, also accounts receivable follow up.
  • Reconciled all payments received from stop loss Carrier/ Maintain outstanding receivables
  • Audited Capitation Deductions Provided by Numerous Health Plans and
  • Submitted Pay & Chase Quarterly Reports to the Health Plan for Reimbursement
  • Provided Monthly Reports to Reflect Recoupment Totals for Each Client.
  • Prepared monthly and periodic reports analyzing the accounts receivable and escalates problems as necessary.
  • Critical Access / Acute Care facility billing
  • Assist Management with related issues to the collection and payer claims.

Confidential, Los Angeles, CA

Healthcare Collections Specialist Inpatient

Responsibilities:

  • Responsible for billing/collection and follow - up related to HMO's, PPO's, Medi-Cal
  • Resolved problems regarding billing and collection matters/ payers & responded to inquiries
  • Followed up calls on delinquent accounts to parents/guarantors and third party payors and secured information needed to obtain payment; maintain account log with history of billing and collection activity.
  • Researched and analyzed account balances, payments and adjustments to assure full payment was received and closed out account in a timely manner.
  • Prepared and batched all adjustment journals, charge reversal forms and payment transfer forms for review and approval.
  • Processed/ create insurance appeals and denials.

Confidential, Culver City, CA

Lead - Financial Billing Coordinator

Responsibilities:

  • Created daily deposit adjustment log accounts receivable record payments according to contract, identify and track notify Secondary or Self Pay status after primary pays.
  • Examined Medicare, HMO, PPO Commercial/Manage care contracts for accurate reimbursement. Audit accounts to ensure procedure / charges are coded correctly verify implants are calculated in accordance with governmental guidelines, worker s compensation carriers as well as patient and secondary payers.
  • Ensured surgery center claims were accurate and the timely collections of accounts from insurance payers.
  • Monitored/ post payments to accounts and verify correct payment by utilizing managed care contracts for accurate reimbursement.
  • Follow up on Medicare/ Secondary payers electronic and hard copy billings.
  • Daily Patient Admit, Verify Patient Insurance Coverage/Authorizations, collect co - payments/ accounts receivable.

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