Medical Claims Examiner, Provider Resolution Analyst
Resume:
Michael Rivers
Philadelphia, Pa., 19135
Home: 215-***-****
Email; ********@***.***
Career Summary:
Diligent, high-energy, versatile Claims Examiner of 15+ years experience, who can work across all levels of an organization. Hands-on leader with an extensive background in insurance claim and benefits/medical policy analysis. Extensive knowledge of insurance products/programs, with dedication to focused satisfaction, quality and service to internal and external associates.
Computer Skills:
Systems: (Benefits) SLIQ (Streamlined Inquiry System), BASIS (Benefit Access System Integrated Solutions), EBM (Enrollment Benefits Memorandum), DMS (Document Management System), Facets system
(Claim Adjustment) Felix/OSCAR, Power MHS, IQPlus (Intellique Plus), CIS (Claims Inventory System), Valutech, Philprov, Corporate Code Set systems.
General: MS word, MS Excel, MS Outlook
Professional Experience:
Horizon New Jersey Health – 1700 American Blvd., Pennington, NJ 08534 (2017 - 2018)
(Acquired through Northpointe Personnel)
Provider Resolution Analyst 3/1/17 – 2/28/18
Worked in the CRU (Check Recovery Unit) of the Finance Department. Accounts Receivable and processed refunded provider payment checks.
Received provider checks and returned Horizon plan checks from providers indicating refunds to Horizon.
Researched and determines if refund is correct.
Logged in refunds and forwarded to adjustment department to complete.
Filed Horizon plan checks
Re-mailed Horizon Plan checks returned for bad address.
Data entry of Horizon plan checks to be voided or re-mailed.
Health Advocate – 3043 Walton Road, Suite 150, Plymouth Meeting, PA 19462 (5 months)
Claims Specialist 6/20/16 – 11/29/2016
Contracted through member’s employer, at member’s request, investigated, reviewed and advised member of resolution of professional and facility medical claim issues.
Confirmed proper authorizations to communicate with providers and insurance carriers to speak and get information on member’s behalf.
Initiated and facilitated communications with clients, providers and insurance carriers to resolve member claim issues.
Independence Blue Cross – 1901 Market Street, Philadelphia PA 19103 (1996 –2015)
Operations Unit: Claims Examiner (Local, Bluecard) 1996 – 2015
Reviewed and adjusted professional and facility medical claims for Personal Choice, Amerihealth and Keystone lines of business.
Initiated communications with customer service reps, professional providers, hospitals and other Bluecard plans for claim resolution
Maintained a “Proficient” (100% - 136.2%) to “Distinguished” (136% or greater) rating in all performance goals/objectives
Consistently met or exceeded claim adjustment production levels
Pilot project: Claims Examiner, Priority Response Team 2011-2014
Recruited to work on a cross-functional Customer Service unit (in tandem with standard Operations Unit
duties): consisting of Customer Services, Enrollment and Claims Examiners, dedicated to intercept and
resolve member claim issues before escalation to executive level.
Investigated and adjusted a series of claims in a project for one member that saved the company about one million dollars
Created and maintained a database of 500 impacted claims
Core Qualifications:
Extensive knowledge of medical billing and coding, health claims and processing insurance claims
In-depth knowledge of medical coding and medical terminology
Skilled in handling multiple tasks and the ability to work under pressure
Outstanding proficiency with Microsoft Office applications such as Outlook, Word, Access and Excel
High problem-solving and organizational skills
Strong provider and claims auditing experience
Proven ability to be self-motivate, work independently as well as part of a team
Strong leadership skills
Solid written and oral communication skills
Highly skilled with 1500 Claims, UB04 Claims, ICD-9, CPT-4, HCPCS and DRG standards and techniques
Experience in HIPAA activities, regulations and compliance
Ability to identify and maps claims to the appropriate practitioners according to service level agreements
Able to work with all levels of management and within budgetary requirements
Assigned team associates IBC associate claims for processing
Lead processor for Personal Choice, AmeriHealth and Keystone Health Plan East lines of business
Provider payment issues senior lead investigator
Awards: Gold Coin Awards for Employee Excellence – 29 awards
Striving to Achieve Results – 2 awards
Education: Philadelphia University of the Arts – Bachelors of Fine Arts
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