Claims Adjuster/Processer Resume

SUMMARY

Highly personable Customer Service Professional with years of experience in configuration, benefits analyst, account management, claims processing, and call - center operations within the insurance, and entertainment industries.
Proficient in processing claims using systems such as ie…Facets, Medical Manager, Diamonds, and ICD-9, ICD 10 and CPT coding.
Expertise in resolving escalated benefit configuration issues.
Proficient with Microsoft Office System (including Microsoft Word, Microsoft Excel, SQL, Microsoft PowerPoint®, Microsoft Access, and Microsoft Outlook®).
Demonstrated ability to gain customer trust and provide exceptional follow-up, leading to increased repeat and referral business.

PROFESSIONAL EXPERIENCE

Confidential

Claims Adjuster/Processer

Responsibilities:

Processed and corrected claims based on denial errors
Made adjustments based on CMS guidelines and Federal Regulations
Researched claim denials in order to make sure claims were processing according to provider contract

Confidential

Benefits Configuration Analyst

Responsibilities:

Workflow support and Facets benefit configuration
Became proficient with using Facets and SQL in order to review Medicare and Medicaid tickets
Completed research and worked projects based on Configuration changes that needed to be made within the system.
Utilized special macros and spreadsheets to research provider inquiries, pends, and Research tickets from members and providers.
Proficient using Facets, IDIRS, SQL (GFO), Access, Query tools

Confidential

Customer Service Representative

Responsibilities:

Assisted customers with enrolling into their medical insurance
Provided customer service to participants enrolling into their spending accounts
Utilized different systems to process enrollment per client restrictions and guidelines