Claims Research & Resolution Specialist

V

MICHAEL GOODSMAN

Indianapolis, IN, ***** 317-***-**** **********@****.***

Claims Research and Resolution

Professional

Pharmacy Claims & Third-Party Adjudication Specialist PharmScript Oct 2018 - Current

• Investigate pharmacy claim discrepancies, insurance denials, and reimbursement issues daily, reducing aged receivables through timely resolution.

• Evaluate customer accounts daily to identify payment solutions, and maintain a high promise- to-pay fulfillment rate.

• Collaborate with insurance carriers, patients, pharmacists, and internal teams to resolve claim exceptions, achieving a high first-contact resolution rate while improving reimbursement turnaround.

• Produce 100% audit-ready account records, documenting claim activity, payment commitments, and customer communications in accordance with company standards and HIPAA compliance requirements.

• Manage a high-volume workload while consistently exceeding departmental productivity, quality, and customer service benchmarks.

State Certified Pharmacy Technician

CVS Pharmacy Dec 2015 - Oct 2018

• Ensured timely dispensing of prescriptions weekly, maintaining 99%+ accuracy and supporting uninterrupted pharmacy operations in a high-volume setting.

• Minimized prescription delays by researching insurance coverage issues, resolving third-party billing rejections, and coordinating with providers and payers to secure claim approvals.

• Strengthened prescription workflow by validating medication information, calculating accurate day supplies, and supporting pharmacists in meeting daily service goals.

• Improved medication availability by monitoring inventory trends, replenishing essential stock, and preventing product shortages.

• Assisted daily patients with inquiries about prescriptions, insurance, and medication, consistently delivering exceptional service while safeguarding confidential health information.

Sales & Customer Service

Condominium Rental Coordinator May 2013 - Present

• Maximize occupancy and revenue across 2 vacation rental properties part-time evenings, maintaining a high annual occupancy rate and enhancing annual rental income.

• Increase guest retention by managing reservations, delivering responsive communication, and personalized service, boosting repeat bookings.

• Safeguard financial accuracy by processing payments, reconciling monthly bank accounts, and administering annual transactions with 100% accuracy.

• Coordinate vendors, maintenance schedules, and property readiness to ensure seamless guest experiences while reducing service disruptions.

• Resolve guest concerns efficiently by evaluating issues, implementing practical solutions, and consistently meeting customer satisfaction targets. EDUCATION

Bachelor of Science (B.S.)

Manchester College

Teacher Certification

IUPUI (Indiana University–Purdue

University Indianapolis)

CERTIFICATION &

LICENSURE

• Insurance Claims Verification &

Case Management

• Claims Investigation & Processing

• Documentation Review & Filing

Quality Improvement

• Database Management & Data

Visualization for Progress

Monitoring

• Delinquency Risk Assessment &

Follow up Strategies

• Accounts Receivable & Collection

• Billing & Payment Issues

Resolution

• Client Relations & Stakeholder

Management

• Strong Communication & Swift

Escalation Handling

• Regulatory Compliance & Audit

Readiness

• Microsoft Office Suite: Word,

Excel. Outlook, PowerPoint

• Framework

• DocuTrack

Detail-oriented and results-driven Claims Research & Resolution Professional with over 10 years of experience in healthcare claims processing, investigation of discrepancies and denials, and provider/payer collaboration. Skilled in conducting root cause analyses of claims data to identify trends in denials, underpayments, and errors; resolving complex reimbursement issues; and educating providers and stakeholders on proper claims submission. Proven ability to exceed productivity and quality standards, deliver exceptional client support, produce 100% audit-ready documentation, and ensure regulatory compliance (HIPAA). Strong communicator with teacher certification, expertise in data management, dispute resolution, and process improvement. PROFESSIONAL EXPERIENCE

• Certified Pharmacy Technician

PROFESSIONAL SKILLS

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