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Claims Examiner

Redondo Beach, CA, 90278
38000.00 per year
September 25, 2008

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Opportunity to utilize my Medicare experiences in the field of a medical claims examiner, analyst, or billing.


Dedicated, dependable, and well organized individual with the ability to prioritize workload. Well adjusted to changing demands of an environment, workload, and production needs. Work well with others and open to change. Flexible and willing to work overtime when needed.


11/2000 to 04/2006 Returned 11/2006--08/2008

Medicare Appeals Examiner

National Heritage Incorporated Los Angeles, California

Audited claims for global surgery and multiple surgery.

Analyze history to determine diagnosis criteria was met.

Interacted with section managers and medical advisors to provide recommendations to enhance processing procedures.

Assisted in training new employees.

Apply diagnosis criteria to laboratory services.

Identify system problems when procedures were denied incorrectly. Reported for correction.

Knowledge of CPT, HCPCS, and ICD-9 codes.

Knowledge of LCD's and NCD's.

Knowledge of modifiers.

Processed and reviewed claims sent in on paper and electronic mail according to Medicare guidelines.

Responsibilities included corrections and/or communications with billing offices and physicians to ensure correct payments. Research utilization guidelines, frequency parameters, correct coding initiatives, diagnosis criteria, and reviewing documentation such as office notes, lab reports, and operative reports. Other responsibilities included telephone review, special projects, and transferring to the correct departments when the mail was misrouted.

Achieved department and CMS requirements for production and quality.

Surpassed requirements when audited.

04/2006 to 10/2006

UCLA Physicians Billing and Collections

Billing and Collections for pathology services.

Work accounts receivable to correct billing errors and follow up on unpaid claims.

Answered telephones and took credit card payments.

10/1998 to 11/2000

Customer Service

Transamerica Insurance Company Los Angeles, CA

Assist Medicare providers and beneficiaries with billing questions and claim information.

Update secondary payer records.

Adjust claims to pay when the denied incorrectly.

Research purged claims from microfilm.

Document all calls and the reasons for the call.

Assisted on the fraud hotline by taking the information and researching the claims before transferring for investigation.

03/1996 to 06/1998

Customer Service

Regence Blue Cross Salt Lake City, Utah

Assisted Medicare beneficiaries with claims information.

Documented all incoming calls.

Followed through with all problems reported on claims.

Researched claims and microfilm of purged information.

Sent out all correspondence that was requested.


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