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Claims Examiner

Houston, TX
November 04, 2019

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**** ******* ****** ****

Houston, TX 77048



Dedicated and technically skilled business professional with a profound track record of processing significant claims. Versatile administrative skill set developed through experience as a Claims Examiner Collector and Senior Claims Analyst. Highly motivated team member that excels in resolving employer challenges with innovative solutions, systems and process improvements proven to increase efficiency, customer satisfaction and the bottom line. Fifteen (15) + years in claims processing, vast experience in EDI, ICD-9 codes, CPT and HCPCS codes, EOBs, HCFA-1500 UB04; DRG, Authorization and Referrals. Worked on Diamond system, EZ-Cap and Citrix. Promote and maintain a professional and positive attitude at all times. EXPERIENCE

Senior Claim Processor Houston, Texas

Manhattan Life September 2015 – December-2018

Apply all claims polices, contracts, practices and keep in compliance with industry regulations and guidelines.

Resolve any grievances and complaints received through Customer Service.

Processes claims based upon contractual agreements, involving the use of established payment methodologies Claims Examiner Houston, Texas

Cigna/Healthspring February 2006 - May 2014

Examines and processes paper claims and/or electronic claims

Determines whether to return, pend, deny or pay claims within policies

Determines steps necessary for adjudication

Follows established departmental policies and procedures, operating memos and corporate policies to resolve claims

Compares application and/or provider statement with policy file and other records to evaluate completeness and validity of claim

Interacts with agents and claimants by mail or phone to correct claim form errors or omissions and to investigate questionable entries

Responsible for independently reviewing complex or specialty claims and providing hands-on training to lower level Claim Associates Claims Examiner Houston, Texas

Heritage Physician Network July 2001 – February 2006

Processes Professional and Hospital Medical Claims

Reviews batches of claims in order to ensure accuracy of payment

Edited and adjusted claims after audit process is complete, assisted other claims examiners as needed

Responded to Member Service Inquiries; make necessary adjustments SKILLS

ICD-9, CPT-4, Coding, Medical Terminology, CRT, Microsoft Word, Detail Oriented & Organized, Analytic, Problem Solving Skills, Team Player, Quick Learner, Hard Worker and Flexible, Excellent Verbal and Writing Skills, Responsible With High Regards to Ethical Behavior EDUCATION/CERTIFICATIONS

Sanford High School 1981

Barclay Career School 1986

Word Processing Certificate

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