Medical Insurance
Resume:
Mary Terrell
Detroit, Michigan **228
abjs1e@r.postjobfree.com
OBJECTIVE: Seeking a medical insurance processor position to process
medical and hospital claims. Analyzed and adjudicate in accordance with
policy, procedures and guidelines.
QUALIFICATIONS
Process various types of claims including CMS-1500 and UB92. Extensive
knowledge of medical terminology, CPT, HCPCS and ICD-9 coding. Proficient
in reviewing departmental and policy to resolve claims issues. Also,
Coordinate Benefits with MSP, Medicare, COB and other coverage's. Research
claims regarding inaccurate payments and non-payment of claims due to
benefits applied incorrectly or system error. Experience in Excel, Word,
Power Point.
Claims Paying Systems-Wgs.2.0,Central Facets, Networx Price, Unicare
Bridge, Lumin X, Amisys, Mits
EMPLOYMENT
2008-2009 Claims Edits Processor-The Jacobson Group-Anthem Wellpoint
-Systems Wgs.2.0 Networx, Facets, Unicare
Resolve Edits when alerted to eligibility: suspend data on procedures code,
diagnosis codes, Timely filling issues and any other types of data
discrepancies. Adjudicate claims in accordance with guidelines, procedures
and maintain production standards with quality. Submit request for
providers file update for Central host and Unicare Bridge to assist claims
processed on WGS, to ensure the correct provider number is being used.
Calculate the pricing amounts refer to rate sheet value and rate sheet
reference on Networx Price/Ship. Process Medicare and Cob claims.
2007-Claims Adjuster-The Jacobson Group-SRC Aetna-System-Lumin X
Adjust claims that were incorrectly denied for multiple co-payments, non-
covered items and claims that reach
a outpatient maximum. Reprocess the claims after system was reconfigured
for auto adjudication.
2007- Claims Examiner-The Jacobson Group WellPoint Health Benefit-System-
Wgs.2.0
Identify claims errors and apply correct benefits. Deductible, co-pays,
late charges corrected claims, keying errors, membership, and provider
updates were all adjust to reflect changes If services were not payable
claim was rejected with appropriate code. If overpayments exist claims were
sent to recovery area.
2001-2005 Claims Examiner-The Wellness Plan HMO-System-Amisys
Perform accurate and timely processing of medical claims submitted by
health care providers. Examines and processes paper claims or electronic
claims. Determines whether to returned, pend, deny or pay claims within
policy provisions. Adjust claims to properly recorded and applied to
correct member when refund checks are return.
1995-2000 Senior Claims Processor-Detroit Medical Center PPO-System-Mitts
Management Information Tracking System
Analyze and adjudicate claims for payment or rejection. Determine
eligibility and interpret insurance policy. Train new examiners to adapt to
specific policies, handle detailed job questions about claims. Handle
voids, refunds, checks, rejections. Review, approve and process medical and
dental claims. Calculate and process adjustment, corrections.
EDUCATION
Diploma Mackenzie High School
Eastern Michigan University
Wayne County Community
Achievement-File clerk in the insurance field, on job training at TPA
became claim processor.
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