Medical Review Analyst Resume Wayne, PA - Hire IT People

SUMMARY

Medical Claims Professional and Certified Professional Coder with extensive experience in applying insurance benefits according to the summary plan description (SPD) when processing claims to ensure the correct processing of claims and resolving and following up on claim appeals and adjustments while at the same time utilizing medical terminology and proper claims coding.

TECHNICAL SKILLS

PROFESSIONAL EXPERIENCE

Confidential, Wayne, PA

Medical Review Analyst

Responsibilities:

Contacted providers, vendors and clients to obtain the necessary medical information for approvals.
Reviewed medical records to determine proper coding: CPT, HCPCS and ICD-9
Researched current industry standards for medical claims review processes
Identified areas of fraud and abuse in Pain Management services resulting in a savings of over $60,000.00 in one case
Approved physical therapy visits up to 18 visits and DME’s up to $1,000.00 for medical necessity
Verified claim benefits to providers and members

Senior Claims Examiner

Confidential

Responsibilities:

Confidential, Frazer PA

Senior Claims Administrator

Responsibilities:

Selected as Special Investigation/Fraud Unit Leader.
Negotiated claim settlements with attorneys and insureds when the claim was in question to ensure minimum expense to the company.
Reduced future claims exposure, by $100,000 by uncovering a block of disability business where eight out of 25 policies should have been cancelled and implemented a plan to cancel the policies.
Identified major potential for speculation, abuse and fraud that led to increased claims savings of $54,000 the first year.
Increased claim savings due to aggressive claims handling that more than doubled in one year from $68,000 to $160,000.
Reduced law suits 64% in the first year of handling fraud and abuse claims.