Medical Claim Examiner

Shefali Shah

Streamwood, IL ***** 630-***-****

linkedin.com/in/shefali-shah-52247628 ***********@*****.***

Medical Claims Analyst

•Analytical, accurate, detail-oriented professional with over 34 years of experience in health care and insurance medical claim adjudication

•Experience with eligibility verification, medical coding, coordination of benefits, and subrogation

•Experience with medical terminology, International Classification of Diseases (ICD) 10, and Current Procedural Terminology (CPT) codes

•Interpret benefit plans, including an understanding of limitations, exclusions, and schedule of benefits

•Strong written, verbal, customer service, decision making, and problem-solving skills for medical claim examination and processing

•Able to work independently and prioritize assignments

•Fluent in Gujarati and Hindi

Areas of expertise:

−Report writing

−Accuracy

−Impartiality

−Time management

−Organization

−Claim verification and handling

−Medical document analysis

−Insurance validation

−Client relations

−Active listening

Technical skills: Proficient Intellis, ACS, Unified Inforce System, RIMS System, UDSE, Disability Process Automation, Javalina, and Microsoft Office systems

Experience

Unite Here Health, Aurora, IL (2014 – 2020)

Claims Adjudicator (Claim Analyst on LinkedIn)

Analyzed and reviewed ~125 group health medical claims daily for accuracy, completeness, and eligibility.

−Helped three other teams process medical claims within strict timelines to ensure payment.

−Received multiple emails recognizing efforts of going above and beyond.

−Provided leadership in reviewing new casino contracts and system set-up to facilitate accurate payments, descriptions, and guidelines.

•Performed test adjudications on recently acquired accounts.

•Interpreted benefit plans, including understanding limitations, exclusions, and benefits.

•Obtained information from plan participants, employers, providers, and other insurance carriers to determine payment liability.

•Evaluated deductibles, co-pays, co-insurances, and other insurance carriers associated with claims.

Shefali Shah

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Experience (continued)

•Followed adjudication policies and procedures to ensure proper payment of claims.

•Provided exceptional customer service to members, providers, and others involved in claim adjudication process through both excellent written and verbal communication.

•Mentored and audited claims processed by trainees and provided feedback when necessary.

•Completed review of pre-authorization claims to determine improvements for auto adjudication.

•Tested new insurance plan for correct benefit adjudication.

MetLife, Mount Prospect, IL (2004 – 2012)

Long-Term Disability (LTD) Claim Specialist, 2009 – 2012

Managed a long-term disability caseload of 100 to 125 claims for nationally recognized accounts.

•Obtained necessary medical information from claimants and provider.

•Collaborated with nursing staff and customer service specialists to thoroughly evaluate claims.

•Performed comprehensive reviews on denied or terminated claims.

•Established action plans for each file to bring claim to resolution.

•Ensured compliance with plan provision guidelines.

•Determined initial and extended benefits due for disability entitlements.

•Coordinated surveillance with special investigation unit as needed.

Short-Term Disability (STD) and Family Medical Leave Act (FMLA) Claim Specialist, 2004 – 2009

Developed, reviewed, and evaluated new and ongoing STD, FMLA, and state mandated claims.

•Analyzed medical documentation and made appropriate decisions in a timely manner.

•Corresponded with employees, supervisors, and physicians via phone, fax, and mail.

•Managed nationally recognized accounts and analyzed contracts.

•Worked with workers’ compensation, state, and social security disability plans.

T.P.A. American Benefits, Naperville, IL (2003 – 2004)

Medical Claim Examiner

Processed group health claims under the RIMS System.

•Answered phone calls from providers and members with a high level of customer service.

Professional Development

B.A., Psychology, Gujarat University, Ahmedabad, India

Contact this candidate