Claims Specialist

***** ******** ***** # *** · HOUSTON, TX *****

210-***-**** · *******@*****.***

HUMBERTO J SANCHEZ

OBJECTIVE

Seeking a rewarding and challenging position in the insurance industry or a healthcare provider setting.

SUMMARY OF QUALIFICATIONS

Extensive experience in the insurance working with private pay, Medicare, third party administration, and worker’s compensation. Extensive knowledge of CPT-4 codes, ICD-9 codes and Coordination of Benefits.

WORK OF EXPERIENCE

2008 - 2009 Coventry HealthCare Claims Examiner San Antonio, TX

Adjusted and processed claims according to Medicare’s guidelines

Readjusted denials/partial denial upon receipt of requested information

Verify individual providers and healthcare contracts

2006 - 2008 United Health Group Claims Examiner San Antonio, TX

Claims Examiner for Southwest Region PPO Reworks Department

Adjust incorrectly paid and denied/partially denied claims

Adhere to patient’s plan provisions and contract language

Adhere to patient’s stop-loss language when required

1997 - 2006 American Admin Grp Sr Claims Examiner San Antonio, TX

Adjusted medical, dental and vision claims in accordance with plans provisions

Answered all correspondence pertaining to pre-existing information, details of accident, coordination of benefits, if applicable, and student status information for dependents per HIPPA guidelines

Supervised the training of 8-10 employees

Assisted in Customer Service Department

Assisted in Appeals Department

Audited claims for Quality Assurance of 8-10 employees

Acted as liaison between examiners and Claims Supervisor

Coordinated all Special Projects including Run-In and Run-Out Plans

References available upon request

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