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Skills

  • Accuracy in medical coding and billing
  • Medical billing codes (CPT, ICD)
  • Budgets
  • Fraud investigation and prevention
  • Client and provider relationship management
  • Compliance with state and federal healthcare regulations (e.g., HIPAA)
  • Claims throughput optimization
  • Time management and prioritization
  • Health insurance regulations knowledge
  • Customer service

Work Experiences

  • Assisted in drafting company-wide standard operating procedures for handling complex claims, decreasing processing errors by 27%.
  • Analyzed cause of denials.
  • Achieved 36% compliance.
  • Was able to effectively communicate with members of the operations, finance, and clinical departments.
  • Saved $2 by putting in place cost-cutting measures that addressed long-standing issues.
  • Adjudicated claims effectively.
  • Reviewed open requests and redirected workloads to ensure that projects were completed on time.
  • Collaborated with human resources to streamline claims submission processes, decreasing average processing time from 17 days to 5 days.
  • Acted as a liaison between providers and insurance companies.
  • Answered 10 calls per 6 months to help customers with their questions and concerns.

Summaries

  • Achieved 22% success rate in appeals process management.
  • Costs were consistently reduced while profits were increased.
  • Within Miscellaneous, senior Medical Claims Representative and outstanding performer in data analysis and cross-functional collaboration.
  • Medical Claims Representative with 14 years of experience, dedicated to providing personalized, courteous service.
  • Overall morale and productivity are boosted by experience in policy development and staff management procedures.
  • Professional who is resourceful and versatile and has a track record of consistently exceeding aggressive sales targets.
  • Achieved 78% reduction in processing delays.
  • Dedicated to learning, growing, and succeeding in Miscellaneous.
  • Achieved a 60% decrease in denied claims appeals backlog.
  • Achieved a 76% improvement in claims processing accuracy.

Accomplishments

  • Managed end-to-end claims process, from intake to resolution, for 5 monthly claims, achieving a 28% resolution rate within one year.
  • Documented and resolved program which led to system.
  • Implemented a flagging system within the claims process to identify high-risk claims, reducing the rate of fraudulent activity by 48%.
  • Contributed to the launch of an internal audit process that helped recover $4 from missed claims opportunities.
  • Utilized data analytics to identify bottlenecks in the claims process, improving claims resolution rates by 36%.
  • Proactively identified and corrected coding errors affecting claims submissions, contributing to a decrease in denied claims by 28%.
  • Designed and led training sessions on the latest insurance policies and claims submission techniques, improving staff performance by 77%.
  • Collaborated with the legal team to revise claims procedures that reduced regulatory compliance risks by 78%.
  • Worked closely with compliance officers to ensure all claims adhered to the latest HIPAA and insurance regulations with a 53% success rate.
  • Resolved product issue through consumer testing.

Affiliations

  • Society for Human Resource Management's Healthcare Interest Group
  • Jaycees
  • Healthcare Financial Management Association (HFMA)
  • International Foundation of Employee Benefit Plans (IFEBP)
  • Association for Supply Chain Management (APICS)
  • American Marketing Association
  • National Association of Social Workers
  • National Employment Law Institute (NELI) - Healthcare Division
  • National Association of Health Data Organizations (NAHDO)
  • International Association of Administrative Professionals

Certifications

  • SHRM Certified Professional (SHRM-CP)
  • Professional Risk Manager (PRM)
  • Certified Professional Biller (CPB)
  • Associate in Claims (AIC)
  • ServSafe
  • Certified Coding Associate (CCA)
  • CompTIA Security+
  • Certified Professional in Healthcare Risk Management (CPHRM)
  • SHRM Senior Certified Professional (SHRM-SCP)
  • Certified Public Accountant

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