Claims Processor Medical
Resume:
Laura Morales
***************@*****.***
Summary
Detail-Orientated Medical Claims processor with experience in professional and institutional claims as well as provider maintenance seeking a challenging and rewarding career in the healthcare industry.
Experience
Health Smart Claims Processor March 2023-September 2023
Processed medical, dental and vision claims
Reviewed medical records for authorizations
Processed professional and facility claims
Corrected and updated provider files
Cigna
Remote Senior Claims Processor June 2022-October 2022
Reviewed and adjudicated medical claims
Conducted research regarding coordination of benefits
Reviewed provider contracts
Manually priced claims
Reviewed and processed insurance to verify medical necessities and coverage under policy guidelines
WebTpa Senior Claims Examiner October 2019-October 2021
Irving, TX
Responsible for day to day processing of medical, dental and vision claims
Applied appropriate procedures and policies in accordance with CMS/Medicare guidelines
Identified and resolved claim edits and denials
Researched plan benefits and verify correct plan loading
Responded to and resolved to provider and member appeals
Manually priced high dollar claims with accuracy
Small Business Administration
Irving, TX Program Support Assistant November 2017- January 2019
Provided administrative and clerical support to legal department
Answered incoming Bilingual calls and made outbound calls to assist clients with loan process
Updated client information in various systems
Prepared letters and documents and scanned incoming mail
Cicerone Health Solutions
Bedford,TX Medical Claims Adjudicator March 2014-March2017
Researched claims, initiated corrections, and updated history
Researched and processed refunds
Applied contract pricing and determined accurate payment
Met and exceeded productivity and quality goals
Addressed and resolved Provider and Member Appeals in a timely manner
Loaded and updated provider files
Skills
Proficiency with Microsoft Windows, Excel, Word, SharePoint, Teams
Understanding of medical terminology with in-depth knowledge of CPT and ICD-09 coding useful in reading medical reports and determining coverage
Knowledge of UB-04 and CMS billing
Knowledge of Medicaid and Medicare
Knowledge of Coordination of Benefits
Contact this candidate