OBJECTIVE
Accomplished claims professional with a proven history of dedication and organizational skills in the insurance field.
QUALIFICATIONS

Extensive knowledge and experience processing HMO, PPO, ASO claims.
Earned distinction as Senior Claims Specialist in my previous position.
Experience as a claims trainer.
Knowledge of CPT and ICD.9 codes.
Experience with Windows, Word, Excel, Outlook, Rims and Idx.
Knowledge of ten key by touch, type 55 wpm, copier, and fax machine.

PROFESSIONAL EXPERIENCE:

Confidential, San Antonio, Texas 2008 to 2010

Senior Technical Claims Specialist
Process routine to complex claims for all physicians, facility, and specialty areas, including Skilled Nursing, Home Health, Dialysis, DME. Claims over $75k as well as adjustments, in accordance with company policies and procedures. Perform peer audits and claims quality review. Investigate, analyze, and resolve outstanding issues to achieve customer satisfaction. Coordinated benefits according to primary carrier explanation of benefits. Processed Medicaid claims. Maintain production and claims quality standard at 100%. Work on special projects assigned by the manager. Participate in senior meetings, training, and workshops to maintain updates on processing guidelines and relay back to the claims department. Serve as claims trainer, mentor, and job coach to the claims department. Assisted call center as needed with calls overflow on a regular basis.

Confidential, San Antonio, Texas 2005 to 2008 Claims Rework Examiner

Responsible for accurate payment of claims based on policy and procedures. Experience with PPO, ASO, and POS claims. Research and adjust payment discrepancies and claim edits to verify appropriate benefit application. Meet productivity goals, quality standards, and time frames. Reviewed and resolved medical claims for provider disputes by determining accurate claim payment based on eligibility, policy provisions, provider contracts, and internal procedures. Issued overpayment requests. Collected all data and documents for provider appeals and forward to Medical Director for reconsideration. Handle special projects assigned by manager.

Confidential, San Antonio, Texas 2003 to 2005

Employment Specialist/Job Coach
Responsible for assisting disabled clients to return to the job market by networking, using the Internet and cold calling for positions that meet the criteria. Instruct individuals with disabilities in a classroom setting on how to fill out applications, resume development, and what is appropriate work behavior and interviewing skills. Instruct on daily living skills hygiene, how to dress, manage their budget, how to set goals, transportation training. How to write checks and balance their accounts. How to resolve conflicts, stress and how to be a team player in the workplace. Responsible for job coaching clients on the job to ensure productivity, and job maintenance efficiently. Maintain records and reports on a daily bases for each client.
Confidential, San Antonio, Texas 1985 to 2005

Manager

Responsible for managing a food to go café with three employees. Responsible for ordering supplies, cooking, and assisting customers. Maintained bookkeeping and payroll records. Responsible for paying all expenses and cashiering.

Confidential, San Antonio, Texas 1991 to 1998
Claims Examiner/Trainer
Responsible for reviewing health related insurance claims for hospitals based on DRG codes. Responsible for claims payment of hospitals and various other specialists based on HMO guidelines. Created training manuals and exams based on different procedures for facility and professional charges. Traveled to affiliated divisions of the company to train staff on claims processing.

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Senior Technical Claims Specialist Resume

San Antonio, TexaS

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