MEDICAL CLAIMS OFFICER
Neuron llc
Total years of experience :7 years, 11 Months
Claims Processing:
Reviewed claim submissions, obtain and verify information, correspond with insurance agents and beneficiaries, and process claim payments.
Thoroughly reviewed the information to ensure that there is no missing or incomplete information.
Validated the information on all medical claims from patients seeking payment from their insurance company.
Recording and maintaining insurance policy and claims information in a database system.
Determining policy coverage and calculating claim amounts.
Processing claim payments.
Kept meticulous records of claims and follow up on lapsed cases.
Have an extensive knowledge of medical terminology, as well as experience using a computer.
Approved or denied payment to doctors knowing how to correctly read and assess medical documents.
Have good communication skills are necessary to converse with doctors' offices or insurance companies if there is a problem with the claim.
Monitored all coding accuracy at various levels of detail and maintains coding quality as needed.
Tracked coding issues and reviews coding inaccuracies to highlight areas of improvement. Reports or resolves escalated issues as necessary.
Provided a high level of technical education and serves as a subject matter specialist regarding coding and documentation.
Supported and educated team members about coding best practices and procedures to meet compliance and regulatory requirements.
Reviewed payment denials, underpayments, and payment take backs for appropriateness and guides resolution by resubmission to the insurance carrier, patient billing, or appropriate adjustment.
Collaborated with interdepartmental or cross-functional teams for assigned projects and provides departments with coding issues and updates to be shared with providers to ensure timely and accurate claim payment.
Complied with organizational policies and procedures.
Claims Auditor:
Performed audits specifically targeting and evaluating procedural diagnosis code selection.
Presented audit findings and identified opportunities within the organization for training.
Identified fraudulent claims.
Monitored, audited and reconciled all documents required for data entry, returns incomplete or questionable documents to generating location or provider.
Collaborate with interdepartmental or cross-functional teams for assigned projects and provides departments with coding issues and updates to be shared with providers to ensure timely and accurate claim payment.
Identified and corrected problems before government and insurance payers could challenge incorrect coding.
Claims submission:
Processed claim forms, adjudicates for provision of deductibles, co-pays, co-insurance maximums and provider settlements.
Wide experience in data entry and medical claim processing
Proficient in submission and editing claims electronically and other on-line systems
Proficient in all computer programs and systems relevant to medical claims
In-depth knowledge of medical terminology useful in reading medical reports and determining coverage
Performed audit of randomly selected claims to ensure quality processing
Maintained and updated all files including insurance companies, diagnosis, procedure, fees/profiles.
Resolved billing issues identified by insurance carriers and patients.
Researched and replied in a timely manner to insurance, patient, and internal customer inquiries.
Maintained the highest levels of accuracy and patient confidentiality
Quickly identified and resolved medical billing, coding and insurance discrepancies
Reviewed patient bills for accuracy and completeness, and obtained any missing information
Researched and resolved denials and EOB rejections within standard billing cycle timeframe
Reviewed billing edits and provided insurance company with correct information
Coding of inpatient and outpatient procedures from operative reports by using ICD 10 and CPT codes and applying modifiers when needed.
Skilled at decision-making, effective communication, analytical and research oriented tasks
Set-up practice management software for submission of electronic claims
Claims Resubmission/Reconciliation:
Resolved problems resulting from claim settlement
Good communication skills are necessary to converse with doctors' offices or insurance companies if there is a problem with the claim.
Reviewed claim denials and payer requirements for corrective action and prevention in the future.
Researched and justified the denied claims to ensure timely payment.
Corrected and resubmitted claims denied by insurance company
Post and reconcile insurance and patient payments.
Research and resolve incorrect payments, EOB rejections, and other issues with outstanding accounts
Profound knowledge regarding anatomy, disease management, and pharmacology.
Possess skills with regard to allotting codes and achieving the information while describing the analysis documented.
Acquainted with the procedures of coding.
Experience with past medical care environment.
Good interpersonal skills and able to function as a team member.
Acquainted with computers and can work on Microsoft Excel, word, Emails and internet.
Excellent verbal written English communication skills.
Efficient while handling the telephone calls.
Ability to maintain confidentiality.
Educational Details: ➢ Bachelor Degree in NURSING, secured 75% from Nizam's Institute of Medical Science, India (2008 -2012)
➢ Intermediate, secured 86.9% from Board of Intermediate Education, India (2006 - 2008)
➢ Secondary School Certificate, secured 87% from Board of Secondary Education, India (2006) Summary of Experience: