Medical Claims Processor with Compliance Expertise
Resume:
SUSAN HOEPPNER
SIOUX FALLS, SD *****
H: 605-***-**** C: 605-***-**** **********@***.*****.***
PROFESSIONAL SUMMARY
Effective Medical Claims Processor with strong background building rapport with providers to discuss claim status or claim denials. Driven performer equipped to handle multiple administrative tasks effectively. Exemplary worker with highly investigative skills when processing claims.
SKILLS
Critical thinking
Customer service
Microsoft Office
Multitasking abilities
Written Communication
Responsible
WORK HISTORY
GOOD SAMERITAN SOCIETY
Senior Administrative Assistant Sioux Falls, SD June 2025- Feb 2026
From June 2025 to Feb 2026, working as a Senior Administrative Assistant.
Entered referral information to get the patient enrolled in to Home Care.
SANFORD HEALTH PLAN
Compliance Auditor Sioux Falls, SD September 2010 – May 2025
From Dec 2021 to May 2025, worked as a Compliance Auditor with the Health Plan.
Verified benefit plans built correctly.
Verified claim processed correctly.
Verified “age off” letters would be sent to the correct members.
From Dec 2012 to Dec 2021, worked as a claims representative for the Health Plan.
Collaborated with claims department and industry anti-fraud organizations to resolve claims.
Prepared summaries of damage, payments and policy coverage.
Processed claims for members.
Researched claims and incident information to deliver solutions and resolve problems.
Consulted police and hospital records when needed.
Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
Reviewed new files to determine current status of injury claim and to develop plan of action.
Handled customer service on a special line of business.
From Sept 2010 to Dec 2012, work in the ICU as a Certified Nurse Aide.
Assist with patients with the RN’s and physicians.
Restocked supplies in patients rooms
Did vitals on patients, assisted with personal hygiene with patients.
VISITING ANGELS
Certified Nurse Aide Sioux Falls, SD June 2020 - February 2021
Assisted clients with personal care, medical duties as needed in the clients home.
Supported ambulation and physical therapy needs by conducting planned exercise routines.
Assisted patients with mobility needs, including moving to and from beds, organizing wheelchairs and preparing assistive devices.
Obtained client medical history, including medication information, symptoms and allergies.
Documenting care given for insurance requirements.
Traveled to clients' homes to complete healthcare services and promote continuity of care.
Reported any unusual or urgent circumstances in patients' condition or environment immediately to nurse supervisor.
LEWIS DRUG
Cashier Sioux Falls, SD December 2018 - November 2019
Answered questions about store policies and addressed customer concerns.
Completed inventory counts and ordered merchandise.
Worked closely with shift manager to solve problems and handle customer concerns.
Operated cash register for cash, check and credit card transactions with excellent accuracy levels.
Promoted customer loyalty and consistent sales by delivering friendly service and knowledgeable assistance.
Helped customers complete purchases, locate items and join reward programs.
LOWES HOME IMPROVEMENT
Cashier Sioux Falls, SD August 2014 - November 2016
Restocked and organized merchandise in front lanes.
Helped customers complete purchases, locate items and join reward programs.
Monitored self-checkout systems and provided assistance or intervention where required.
Worked closely with shift manager to solve problems and handle customer concerns.
Operated cash register for cash, check and credit card transactions with excellent accuracy levels.
Reviewed weekly sales ads and monitored price changes.
WELLMARK BLUECROSS AND BLUESHIELD OF SD
Claims Adjudicator Sioux Falls, SD June 1996 - September 2010
Investigated high volume of insurance claims to determine validity and coverage eligibility.
Executed claims processing, while generating increased revenue.
Collaborated with claims department and industry anti-fraud organizations to resolve claims.
Reviewed new files to determine current status of injury claim and to develop plan of action.
Optimized organizational efficiency by mentoring personnel on customer service protocols.
Determined claim status and negotiated to reach reasonable settlements or denials.
Answered members phone calls and assisted on solving the members concerns.
Handle the TTD lines for members.
FIRST HEALTH
Claims Examiner and processer, Customer Service Sioux Falls, SD January 1994 - June 1996
Reviewed new files to determine current status of injury claim and to develop plan of action.
Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
Interviewed claimants and witnesses to gather factual information.
Verified insurance claims and determined fair amount for settlement.
Investigated properties to determine extent of damage and estimate repair costs.
Prepared summaries of damage, payments and policy coverage.
EDUCATION
Colorado Technical University-- Business Administration and Accounting—degree not completed
Sioux Falls, SD
HIGH SCHOOL DIPLOMA
Lincoln High School
Sioux Falls, SD, 1979
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