Sample Resume for Medical Claims Examiner

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Medical Claims Examiners are in charge of following insurance procedures and submitting claims. Other duties include reviewing settled insurance claims to determine that payments and settlements have been made in accordance with company practices and procedures, reporting overpayments, underpayments, and other irregularities, and conferring with legal counsel on claims requiring litigation.

A resume for medical claims examiner position should exhibit excellent accounting skills, communication abilities, accuracy, and IT skills.

Consider the following resume sample for medical claims examiner position:

 

 

Medical Claims Examiner Resume Sample

 

 

Dan Byrd
3498 Example Street, Austin, Texas 30586
(049) 835-6537
dan@email.com

MEDICAL CLAIMS EXAMINER

SUMMARY
A certified medical claims examiner with more than 5 years’ experience and a solid track record of determining the eligibility of the claims filed. I am competent at resolving medical claims by approving or denying documentation; calculating benefit due; initiating a payment or composing denial letter.

PROFESSIONAL COMPETENCIES

Batching Prioritizing Account Verification
Claims Processing Claims Identification Review
Fraud Determination Adjustments Forms Handling
Follow-up Resubmission Documentation

ACCOMPLISHMENTS
• Achieved “Top Performer Awards” for 1995 and 1996, which consists of high performance and quality.
• Introduced processing idea, which was implemented throughout the corporation, saving the company $6,500 annually.
• Implemented a unique claims processing system, which reduced the processing time by 65%.

PROFESSIONAL EXPERIENCE

Medical Claims Examiner
XYZ Healthcare, Austin, Texas | June 2015-present
• Document medical claims actions by completing forms, reports, logs, and records.
• Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.
• Process claims for both inpatient and outpatient clients.
• Prepare reports to be submitted to the company’s data processing department.
• Pay and process claims within designated authority level.
• Negotiate claim settlements and make recommendations for legal action when settlements are deemed non-negotiable.
• Adhere to all company policies, procedures, and guidelines in addition to insurance regulations at the federal and state level.
• Ensure all claims information remains confidential.
Medical Claims Examiner
ABC Healthcare, Austin, Texas | March 2013-May 2015

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• Investigated claims to ensure they were not fraudulent.
• Determined if the policy of the insured covered the loss claimed.
• Negotiated settlements to avoid going to court and authorized payments.
• Obtained additional information from claimants’ doctors on questionable claims.
• Referred questionable claims to outside field investigators.
EDUCATION
AS Degree in Accounting
XXX Technical College, Austin, Texas – 2012