Analyst, Claims Resume Samples

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L Runte

Lamar

Runte

8218 Floyd Lake

Houston

+1 (555) 487 6185

8218 Floyd Lake

Houston

Phone

p +1 (555) 487 6185

Experience Experience

Houston, TX

Claims Quality Analyst

Houston, TX

Hintz and Sons

Houston, TX

Claims Quality Analyst

Analyze and identify trends and provide feedback and reports to reduce errors and improve claims processes and performance
Create, maintain and track reports in relation to performance
Analyze information and utilize to build recommendations to reduce errors and improve process performance
Develop management reports detailing the review process findings as well as trending/analysis reports
Develops and executes claims test plans for vendor implementations or system upgrades
Manages the pended claims queues and monitors daily claims inventory and work flow
Serves as the internal claims subject matter expert and provides guidance as requested or as necessary

San Francisco, CA

Claims Root Cause Analyst

San Francisco, CA

Towne, Moen and Ward

San Francisco, CA

Claims Root Cause Analyst

Performs extensive reviews on member or provider claim issues to determine root cause analysis. Documents, tracks, resolve and reports findings back to Administration
Complies with company policies and procedures, which includes punctuality as they relate to work time, lunch, and break period
Maintains knowledge of changing member benefits and provider contracts
Maintains QA Standards as established in SWHP QA program
Works independently or as a team member to meet or exceed customer expectations
Provides an enhanced level of Claims knowledge and assistance for the SWHP Customer Service Advocates. Handles next level (supervisory) caller issues escalated from the Customer Service Department. Properly responds and follows up on any outstanding issues
Ensures that the Claims Provider Manual is accurate and edits are incorporated in a timely manner to ensure accurate information is communicated to the providers

present

Phoenix, AZ

Senior Claims & Risk Analyst

Phoenix, AZ

Reichert, Smith and Torphy

present

Phoenix, AZ

Senior Claims & Risk Analyst

present

Coordinate claim review meetings with insurance carriers and work closely with adjusters to develop claim closure strategies
Conduct property loss control visits and manage progress
Respond to insurance and risk management inquiries, concerns, and questions
Assist in serving as liaison between the company, the brokers, the carriers, and the attorneys involved in various insurance matters
Maintain claim database by assisting in loss trending, loss forecasting and data analysis
Work with business units on complex claims and reserve & settlement recommendations
Assist with insurance coverage placements

Education Education

Bachelor’s Degree in Accuracy

University of Pittsburgh

Bachelor’s Degree in Accuracy

Skills Skills

Excellent communication skills; both written and verbal
Edifecs knowledge is desired
Attention to detail
Time management skills; capable of multi-tasking and prioritizing work
Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
Ability to work independently and within a team environment
Advanced computer skills
Demonstrated understanding of claims operations specifically related encounters
Data analysis and trending skills

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15 Analyst, Claims resume templates

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Claims Initiation Analyst Resume Examples & Samples

Adapts well to an ever changing environment
Ability to multi-task as business needs dictate with phone and typing required
Ability to work i

Claims Project Analyst Resume Examples & Samples

Responsible to participate and coordinate the delivery of projects that are generally confined department specific initiatives. May provide solutions to identified issues under guidance of project managers
Assists in the design, development, prioritizing and implementation of system updates and enhancements. Participates in system testing and the troubleshooting and problem resolution of system issues and errors. ay also complete Claims intranet design, development and enhancements
Participates in the development of forms and documents
Bachelor’s Degree or relevant experience
Verbal and written communication skills. Interpersonal skills
Ability to work having a high degree of accuracy; strong attention to detail
Experience with personal lines claims settlement. Previous experience in project coordination

Claims Project Analyst Resume Examples & Samples

Responsible for participation in and coordination of the delivery of medium scope projects that are generally confined department specific initiatives. Provide input on solutions to identified issues under guidance of project managers
Lead and is responsible for the delivery of department specific, small scope projects. Manage projects within the company's project delivery framework and utilizes company/industry standard project management methodologies and tools. Accountable for project communication and escalation of critical issues to project sponsors and stakeholders. Provide input on solutions to identified issues under guidance of project managers
Coordination of activities related to vendor management
1-3 years of relevant claims experience
Knowledge of state compliance regulations including the ability to interpret state statues associated with assigned product
Ability to work having a high degree of accuracy; strong attention to detail. Previous experience in project coordination
Experience with personal lines claims settlement

Claims Cost Reasearch & Opportunity Analyst Resume Examples & Samples

Ability to read and interpret physician and/or facility contract language
2 years or more of medical, Medicare, Medicaid and/or Commercial claims experience
Proven experience with facility and/or physician medical claims payment reimbursement
Proven experience analyzing data and identifying trends
Excellent time management and ability to work under minimum supervision
Proven examples of utilizing Microsoft Word, Excel (ability to manipulate/filter)
Claims adjudication experience
Provider At A Glance, Contract Information System
Strong operational understanding of provider payment networks or capitation systems and how they impact claim processing and provider relationships

Claims Initiation Analyst Resume Examples & Samples

6 plus months of customer service experience
Works well independently
Strong ownership skills
Call Center Experience

Senior Analyst, WC Claims Resume Examples & Samples

Independently manages Workers’ Compensation indemnity claims for the Company within an assigned geographical area ensuring compliance with applicable jurisdictional rules and regulations
Acts as liaison between employees, TPA (Third Party Administrator) adjustors, TWC business partners, internal and external legal counsel and other appropriate parties serving as a Workers’ Compensation subject matter expert for the Company. Provides claim direction to the Workers’ Compensation TPA adjusters and provides recommendations for claim handling and resolution within a predetermined amount of monetary authority. Oversees assigned defense counsel for litigated claims
Monitors progression of injured employee’s progress to achieve optimum medical recovery and expedient return to work. Coordinates return to work ensuring that appropriate communication takes place with TWC business partners and ensures that the employee is returned safely to work within their restrictions (if any). Maintains contact with injured employee
Reviews data to determine necessary claims process changes. Runs and analyzes reports for internal customers. Engages with EHS (Environmental Health & Safety) partners to identify and address adverse trends
Travels to and is the Company representative at hearings, mediations, and trials as required
Assists with training of TWC personnel throughout the organization. Mentors Claims Analyst(s) providing indirect oversight of their work and guidance in assessing claims
Advanced knowledge working with Microsoft Office products and RMIS systems
Excellent communication, planning and organizational skills with the ability to prioritize multiple and complex tasks in a fast-paced environment
Strong analytical skills and performance of root cause analysis; ability to think through details
Strong report writing and presentation skills
Ability to guide, motivate and mentor more junior staff

Analyst, Claims Resume Examples & Samples

More than 2 years experience within financial services Operations
Very good knowledge of Operational processes and systems
Very Good understanding of workflows in relation with custody and TA business
Organized, and able to deal with constantly changing volumes, deadlines and complexity of transactions
Building partnerships with stakeholders
Shapes the future
Lead with integrity
Drives to succeed with a focus to win
Strong verbal and written communication and negotiation skills

Claims & Disbursements Analyst Resume Examples & Samples

Review contract - ensure minimal or nil exposure at our end if possible (between counterparties & charter party/owners)
Process non demurrage claim- Shifting / Port Costs / Bunkers / heating / speed up / deviation
Reporting to the management
Understanding of basic shipping terms and oil tankers operation
Understanding of shipping industry and specifically operations and claims department functions

Claims Quality Analyst Resume Examples & Samples

Provide claims support by reviewing, researching, investigating, auditing claims
Medicaid and/or Medicare appeals and grievance experience is required to have, and claims and adjustment experience is valuable to have
1+ year of experience analyzing and solving customer problems in an office setting environment
Medicaid or Medicare appeals and/or grievance experience
Moderate proficiency with computers and Windows PC applications (this includes the ability to learn new and complex computer system applications)
Basic proficiency with Microsoft Excel (ability to work in a spreadsheet and save a spreadsheet)
3+ years of working experience in claims processing or quality
Ability to multi-task (this includes ability to understand multiple products and multiple levels of benefits within each product)

Analyst, Claims Resume Examples & Samples

Excellent communication skills (Oral and written)
Proficient in Microsoft Word, Outlook and ability to navigate through Access
Fundamental understanding of the home warranty industry
Ability to keep composure in hostile conversations
Bachelors Degree or commensurate work experience
1-2 years of previous customer service experience
Previous leadership experience desired but not required (experience could be work related, school or extracurricular activities related)
Paralegal certificate desirable but not required

Claims Quality Analyst Resume Examples & Samples

Positions in this function are responsible for all aspects of quality assurance within the Claims job family. Conducts audits and provides feedback to reduce errors and improve processes and performance
1+ year of Appeals and Grievances experience
2+ years of experience with computers and Windows PC applications, this includes the ability to learn new and complex computer system applications
2+ years of experience with Microsoft Excel - sort data, create very basic tables/graphs, Word - know how to open a new document and be able to save, and Outlook - corresponding via email and how to make appts
Experience with Medicare Part C
Experience in claims processing or quality

Claims Quality Analyst Resume Examples & Samples

Manages the pended claims queues and monitors daily claims inventory and work flow
Facilitates the claims adjustment process and system remediation as required
Conducts weekly quality assurance review of member explanation of benefits (EOBs) and provider’s Remittance Advice (RA), provides vendor feedback to the Claims Manager, as necessary
Reviews daily production reports in conjunction with the Claims Manager and/or Director of Operations
Serves as the internal claims subject matter expert and provides guidance as requested or as necessary
Identifies and conducts focused and random claims audits
Receives and researches claims issues identified by TPA and internal departments
Interfaces with vendors to facilitate external claim reviews
Regularly monitors claims processing contractual compliance with CMS requirements including managing the collection and submission of required operational performance metrics and data reporting requirements
Monitors and analyzes operational performance metrics, quality assurance and turn-around-time standards when indicated
Develops and executes claims test plans for vendor implementations or system upgrades
Administers claim functions in support of corporate recovery strategies
Develop and maintain claims payment procedures in support of increasing auto-adjudication rates
Conducts high dollar claims review and works with reinsurance vendor to file claims
Assists the Claims Manager and/or the Director of Operations with planning and development of the annual and ongoing system configuration and other business activities associated with a project schedule
Maintains a favorable working relationship with all internal and external stakeholders to foster and promote a cooperative and harmonious working climate which will be conducive to maximum employee morale, productivity, and efficiency/effectiveness
Represent QualChoice Health in a courteous manner in attitude and appearance, behaving ethically and using a professional demeanor in oral and written communications with internal and external customers
Adhere to all company compliance standards
Bachelor’s degree in information systems, business or health care administration, or other related field OR a minimum of 4 years of experience in a directly related field
Minimum three (3) years managed care/health plan claims operations experience required, with proven broad knowledge and execution of quality improvement methods and tools
Minimum of two (2) years’ experience in adjudicating claims
Advanced proficiency in MS Office Suite of products
Knowledge of industry standard codes
Must possess strong problem-solving skills and have the ability to multi-task in an effective and organized manner
Ability to establish and maintain good working relationships with staff, external customers and government agencies, as necessary
Understanding of government billing regulations, including; Medicare, Medicare Managed Care, and Medical Terminology

Claims Quality Analyst Resume Examples & Samples

1+ years of experience analyzing and solving customer problems in an office setting environment
1+ years of Appeals and Grievances experience
2+ years of experience with Microsoft Excel (sort data, create very basic tables/graphs)
2+ years of experience with Microsoft Word (know how to open a new document and be able to save)
2+ years of experience with Microsoft Outlook (corresponding via email and how to make appts)

Senior Claims Quality Analyst Resume Examples & Samples

Provide feedback to team members on audit results
Analyze and identify trends and provides feedback and reports to reduce errors and improve claims processes and performance
This is a quality role within the Optum Payment Integrity transaction organization. Major responsibilities of this role include
Validate the accuracy of the decisions made by Referral and Validation, Sanctions, Flag Management and Check Stop teams within the Fraud Waste Abuse and Error business units
Develops and delivers fact-based audit determinations
Serves on applicable cross-organizational quality committees/work groups to identify/ communicate common quality issues, trends and patterns (e.g., Quality Council)
2+ years of experience utilizing claims platforms such as UNET, NICE, Pulse, COSMOS, FACETS, and/or Diamond
2+ years of Fraud, Waste and Abuse experience
Experience with Microsoft Excel (create/update spreadsheets, pivot tables, sorting)
1+ years of quality experience in healthcare industry
Process Improvement Experience

Claims Quality Analyst Resume Examples & Samples

1+ years of working experience in claims processing COSMOS and/or UNET platforms
Intermediate level of proficiency with Microsoft Excel (create PIVOT tables, graphing, save, and report) and PowerPoint (create slides and presentations)
Undergraduate Degree or higher

Claims Field Analyst Resume Examples & Samples

Prepare estimates and reach agreed prices for repairs on insured and claimant vehicles
Handle additional repair orders and special assignments for the claim offices
Handle large catastrophe losses and function as team leader when called upon. This may also include settlement of loss
Initiate the total loss handling process for conclusion by the Claim Offices
Assist in other geographic locations at the direction of claim management
Participate in training, educational activities, regulatory compliance awareness and maintain appropriate licensing and continuing education requirements
4 + years in customer service or financial services industry is needed. Prior leadership experience is needed. Education may be used as a proxy for experience
Knowledge of and exposure to fundamental theories, principles and concepts
Leveraging technical expertise and relationships to contribute to strategy and drive business results

Claims WFM Analyst Resume Examples & Samples

Background and/or knowledge of FEP systems is preferred
Experience with Business Objects is a plus
Must have a strong background with MS Excel
Experience with MS Access is preferred

Senior Analyst, No Fault Claims Analytics Resume Examples & Samples

Support U.S. Consumer Markets No Fault Field Claims Organization
Lead own work streams on most projects. Manage aspects of moderate to complex projects
Bachelor's Degree in business, economics, or other quantitative field
Proficiency with Microsoft Power Point and Excel required
Proficiency with SAS, SQL or other database language required
Experience with Think-cell and PowerPivot is a plus

Senior Analyst, Claims Resume Examples & Samples

Revise claims and render a decision to clients in the shortest possible delay
Provide advice and offer support to clients in regards to group and individual insurance claims procedures
Revise litigated claims and, if needed, make recommendations
Validate claims files with discrepancies between data submitted and system data to permit their payment
Proceed to the upload and validation of clients data via the electronic data transfer system
Communicate with clients to validate data received and request adjustments, if required, in order to improve the quality of the information processed
Support the claims technicians when needed
Provide support in client audits
Could be required to make presentations on specific claims aspects
Curiosity and good analytical and judgement skills
Sense of initiative and skills demonstrated for decision-making
Interpersonal skills and skills for developing efficient relationships with clients
Solid technical expertise and attention to detail in case revision
Organization and good management of priorities and respect for deadlines
Creative and soft spirit all while showing discernment
Autonomous and ease of learning

Claims Management Analyst Resume Examples & Samples

10+ years claim adjusting experience in complex claims handling, including General Liabilty, Auto and Bodily Injury
Excellent organizational, analytical and investigative skills, the ability to work effectively independently and in a team environment, and proficiency in MS Office, Word and Excel required
Strong interpersonal skills, good judgment, and be capable of communicating with a diverse range
Carrier experience is preferred and or combination of carrier and TPA experience
License/Certification- Multi-state adjuster license preferred
Willingness to study and pass exams to be licensed and or certified in 29 states and maintain continuing education
Bachelors Degree or Work Equivalent - Relevant designations preferred (ARM, CPCU, WCCA, etc.)

Analyst, SIU Claims Resume Examples & Samples

Assist internal and external customers with understanding of SIU functionality and process flows
Document business requirements, regulatory requirements and technical details, utilizing a variety of tools including Word, Excel, Visio, Power Point and other tools as applicable
Use data analysis to validate findings via operational report exports and SQL queries
Identify system enhancements that will improve business processes and support future business needs
Learn new technologies and systems to advance knowledge of operation and process improvements
Develop detailed technical design for workflow automation, and implement system changes including monitoring for successful and intended outcomes
Lead and facilitate meetings with project team, including end users, management, and IS team members
Utilize operational and system knowledge to provide recommendations for increased efficiencies and automation through proprietary workflow system
Bachelor’s Degree in Health Information Management, Health Care Administration, Nursing or related clinical field; Public Health, Criminal Justice, Law Enforcement or related field, required. Master’s Degree, preferred
Proficiency in Fraud, Waste and Abuse Auditing
Previous Fraud, Waste and Abuse/ Special Investigations experience
Five (5) years healthcare experience (Managed Care setting preferred)
Proficiency in Microsoft Excel, Word, Visio, Power Point
Proficiency in Microsoft Access/ SQL preferred
Beginner/Intermediate knowledge with database query tools such as AS/400 or SQL
Experience in process automation or technology solutions to support the healthcare market
Ability to handle multiple project simultaneously

Analyst, Claims Resume Examples & Samples

Performs quality audits of claims data as required
Maintains current knowledge of required systems, procedures, forms and manuals as related to claim processing
Bachelor’s Degree in Business Administration or related field, required
Minimum one (1) year health insurance experience required, including working knowledge of claims processing and understanding of billing and claims data
Intermediate knowledge of excel, including pivot tables, required
Excellent interpersonal, communication and writing skills, required

Senior Analyst, Claims Management Resume Examples & Samples

Effectively investigate and manage claims through the company’s third party administrator. This includes, but is not limited to, contacting, interviewing and reviewing records of injured employees, witnesses, attorneys, etc. to secure necessary information and evaluate compensability and settlement of claims by TPA
Lead operations, safety and sales management to define and implement new processes aimed to support the organization in claim prevention and loss control
Utilize knowledge of industry best practices to plan strategic efforts for reducing risk, control costs and maintain legal compliance related to fleet and wholesaler operations
Review work activity in TPA software system to maintain paperless files; Monitor electronic diaries for timely follow up of claims activities. Analyze and support internal investigation through global incident database
Assist in-house counsel in the management of litigated claims according to company practices and procedures
Where appropriate, negotiate and resolve claims promptly within settlement authority. Oversite of A-B facility process for obtaining releases or compensation agreements and submittal of local payments
Develop and maintain professional working relationships with existing vendors (attorney firms, investigation companies, benefit managers, etc.)
Review status reports and participate in claim review meetings
Compile and analyze claims data for various internal and external reporting
Develop comprehensive, streamlined guidelines, training materials and procedures for handling claims
Educational Requirements

Senior Claims Configuration Analyst Resume Examples & Samples

3+ years configuration experience working in a business configurable system
3+ years of experience identifying patterns within quantitative data, drawing conclusions and recommending solutions and approaches, skilled with end to end issue resolution
Excellent oral and written communication skills, interpersonal skills and organizational abilities are essential
Ability to work effectively with minor supervision
Claims Analysis knowledge

Claims Quality Analyst Resume Examples & Samples

Ensure the consistent, accurate, efficient, and appropriate processing of adjustments and/or duplicate claims through an audit sampling review process
3-5 years of relevant, progressive experience in the area of specialization
Experience in claims and/or inquiry processing or equivalent experience in quality
Detailed understanding of the various claims and inquiry processing arrangements, the related Member Touchpoint Measures (MTM) performance standards, and process improvement methodologies
Proficiency with reporting and analytical software tools and a strong knowledge of systems utilized throughout the company Operations Division

Analyst, Workers Comp Claims Resume Examples & Samples

This position acts as oversight by performing a thorough review for proper claim strategy and reserving of assigned indemnity and medical only claims
Reviews are focused on ensurng the TPA adheres to Best Practice claims management. The role is responsible for escalating of the TPA’s failure to demonstrate Best Practice claims management in any pending workers’ compensation claim
Communicate with the TPA adjuster on a daily basis to develop strategies and document a clear plan of action to closure on all assigned claims. Ensure TPA is employing proper techniques to mitigate claims expense including, but not limited to: medical care is consistent to control for overutilization, defense attorneys are using using tactics to reduce litigation expense and all other vendors are properly utilized to avoid costs to the claim without value to the claim outcome
Review and approve all requests for Telephonic case Management or Field Case management requiring clear documentation consistent with injury guidelines
Review, approve and manage legal referrals consistent with established claims management protocols
Review all requests for claim denials and ensure proper strategy through conclusion
Review monthly loss runs and claim trends to identify opportunites
Document client conversations using Saleforce as client relationship software
Attend Quarterly claim review with Senior Manager as needed
Escalate concerns regarding claim quality and outcomes to Senior Manager
Minimum five to seven years of claims adjusting experience required
Multi-state
Strong knowledge and understanding of both state and federal employment laws
Minimal travel required, no more than 20%
Work in clean, pleasant, and comfortable office setting

Senior Claims & Risk Analyst Resume Examples & Samples

Oversee administration of all Workers’ Compensation, Auto Liability, and General Liability claims to include accident investigation involving considerable contact with business units, employee, claimants, third parties, vendors, and in house/outside legal counsel
Work with business units on complex claims and reserve & settlement recommendations
Coordinate all activities on claims handled by current and past insurance carriers/third-party administrators
Coordinate claim review meetings with insurance carriers and work closely with adjusters to develop claim closure strategies
Maintain claim database by assisting in loss trending, loss forecasting and data analysis
Assist with insurance coverage placements
Obtain underwriting data in a timely and orderly fashion to help obtain the broadest insurance coverage at the most optimal value cost to the organization
Assist in serving as liaison between the company, the brokers, the carriers, and the attorneys involved in various insurance matters
Assist with reviewing agreements and contracts for legal and business units for all areas of insurance coverage requirements
Coordinate issuance and receipt of insurance certificates and bonds
Conduct property loss control visits and manage progress
Partner with safety and environmental contacts on risk and insurance matters
Review all insurance invoices to verify all premium payments for accuracy and processing
Maintain accurate and current policy information, records, and files
Respond to insurance and risk management inquiries, concerns, and questions
Limited travel
4+ years of handling/oversight in workers’ compensation claims or related experience including a thorough knowledge of insurance, contractors, claims, and terminology
Familiarity with laws, rules, regulations pertaining to insurance, business law, and third party liability
Ability to think critically, solve problems, plan, organize activities, negotiate, and effectively communicate verbally and in writing
Analytical skill necessary to make decisions and resolve issues
Persuasion and negotiation skills
Proficiency in PC skills including MS Office (Outlook, Excel, Word, PowerPoint) and claims databases are required

Claims Project Analyst Resume Examples & Samples

Assist in all phases of project management: project planning, implementation and monitoring results
Technical resource for converting moderately complex business issues into viable solutions through documentation and analytical sessions with matrix partners
Assist in maintaining all project related materials (e.g. action plans, tracking tools)
Coordinate project activity and facilitate project meetings with staff and matrix partners
Act as subject matter expert by providing technical assistance and guidance to management and associates on operational issues, process changes and activity status
Perform all other related duties as assigned by manager
May also assist in preparing various reports that cover forecast reports, budget status, and other management related reports
Develop and maintain correspondence (scripts, letters, educational materials) for large projects
Required 3+ years of experience in project oversight and administration
Preferred Other Healthcare industry experience
Intermediate Ability to analyze information and covert related activities into a comprehensive work plan
Intermediate Ability to analyze and interpret financial data in order to coordinate the preparation of financial records

Senior Claims Encounter Analyst Resume Examples & Samples

Compile and analyze Encounter data. Understand the financial and clinical impact of changes and decisions to the business process to ensure that the Service Level Agreements (SLAs) are achieved
Provide analytical support and leadership for Claims Encounters Regulatory Data projects
Responsible for reviewing Encounter rejections and providing resolution of minor to complex data issues or process changes
Provide Claims Encounter Subject Matter Expertise (SME) for both CMS and State agencies and internal CareSource impacted organizations (IT, Claims, New Business, Enrollment, etc.)
Build, sustain and leverage relationships with persons within his/her responsibility to constantly allow for continuous improvement of the Encounter Data business process
Direct responsibility for the design, testing & delivery of supporting processes to the business
Lead the claims data processes to ensure accuracy and compliance with CMS and state agencies
Provide support for other key claims data management and readiness to state and governing entities
Understand the Claims Encounter Data requirements in detail to enable one to lead efforts to ensure claims data submissions achieve the required SLAs through requested changes internally and externally
Recognize inconsistencies and gaps to improve productivity, accuracy and data usability and streamlining procedures and policies
Responsible for Claims Encounters regulatory reporting
Provide critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
Prepare and monitor various management and oversight metrics and reports as required
Lead Claims Encounter initiatives such as working with IT and others internal departments to automate Claims Encounters functions; improve regulatory report development with SIS
Provide support of vendors, managing SLA’s, regulatory requirements and contractual metrics
Maintain positive and strategic relationships with internal and external stakeholders
Contribute to and/or develop user stories or provide user story guidance for sprint planning
Understanding of how claims payment methodologies, adjudication processing and State Encounter regulations interrelate to maintain compliant Encounter reconciliation processes and SLA’s
Bachelor’s degree or equivalent years of relevant work experience is required
Minimum of five (5) years of managed healthcare, claims, or managed care regulated environment experience is required
Edifecs knowledge is desired
Data analysis and trending skills
Demonstrated understanding of claims operations specifically related encounters
Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
Knowledge of Claims IT processes/systems required
Knowledge of claims analytic processes/systems required
Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
Experience with 837O files to States and/or CMS (MA EDS) preferred
Experience with 835 files preferred
Time management skills; capable of multi-tasking and prioritizing work
Effective decision making / problem solving skills
Critical thinking and listening skills

Claims Root Cause Analyst Resume Examples & Samples

Performs extensive reviews on member or provider claim issues to determine root cause analysis. Documents, tracks, resolve and reports findings back to Administration
Provides expert assistance to other staff, members, providers and Administration by researching and resolving claims payment issues resulting from configuration or processing errors. Follows up with appropriate department to resolve front end issue
Participates in assessing SWHPs Administrative written response to highly sensitive provider appeals that result in an adjustment to previously processed claims
Provides an enhanced level of Claims knowledge and assistance for the SWHP Customer Service Advocates. Handles next level (supervisory) caller issues escalated from the Customer Service Department. Properly responds and follows up on any outstanding issues
Personally special handles individual provider issues through phone calls, service forms or correspondence for final resolution
Practices good phone etiquette and uses effective communication skills (both verbal and written). Remains cool and calm in stressful situations
Works independently or as a team member to meet or exceed customer expectations
Maintains the provider and member spreadsheet located on the Claims Operations shared drive by documenting and tracking provider issues to enhance provider satisfaction
Obtains information and responds to questions regarding third party liability and acts as liaison to members and providers in accordance with established policies and procedures
Receives other insurance information appropriately and notifies the appropriate SWHP department in a timely manner
Maintains knowledge of changing member benefits and provider contracts
Ensures that the Claims Provider Manual is accurate and edits are incorporated in a timely manner to ensure accurate information is communicated to the providers
Accurately documents phone log records for each customer inquiry. Adjusts claims payment and enters appropriate claim remarks when necessary or forwards request to appropriate area for reprocessing or recoupment
Maintains QA Standards as established in SWHP QA program
Participates as requested in SWHP quality improvement activities
Participates in various committees as assigned
Assists with special projects as necessary
Coordination of complaints for Medical Director w/members to facilitate resolution of those complaints
Performs other position appropriate duties as required in a competent, professional and courteous manner
May be required to work in excess of regular scheduled hours
Focuses on achieving departmental and organizations objectives
Complies with company policies and procedures, which includes punctuality as they relate to work time, lunch, and break period
High school diploma or equivalent (G.E.D.)
Previous Claims processing experience preferred
Health care or HMO experience is preferred
Analytical and problem solving skills; ability to multi-task; strong organizational, interpersonal, verbal and written communication skills are required
Proficient in all SWHP operating systems
Experience negotiating depending on skill level and background
Group 1 license preferred but not required

Analyst, MI & Conventional Claims Resume Examples & Samples

Design Process Enhancements in the clam process
Understand the process and complete data mapping
Analyze data to ensure correctness of reports created
Facilitate the accurate and timely submission of reports
Develop automation of processes to improve quality and reduce cycle time
Perform loss and root cause analysis to identify issues and implement associated action plans to ensure future losses are avoided
Communicate with external business partners to resolve escalated issues, and bring them to resolution
Work independently on projects and other assignments
Multi-task and troubleshoot any issues that may arise and work closely within the department and with other Ocwen departments to ensure their prompt and accurate resolution
Maintenance & Development of existing databases, tables and tools used by Claims processes
Create reporting presentations to be reviewed by Sr. Management
Work in dynamic work culture to create impactful data driven solution to complex business problems
2+ years of experience in reporting and/or analytics
Experience with Mortgage Insurance and/or Collections a plus
Ability to reason and exercise sound judgment
Problems can be somewhat complex and require a systematic, organized approach to resolve

Claims Field Analyst Resume Examples & Samples

1-2 years of Automotive industry experience is needed. Education may be used as a proxy for experience
Typically requires intermediate knowledge of Microsoft Office Programs
Licensed, and or capable of obtaining required state licensing

Claims Portfolio Analyst Resume Examples & Samples

Excellent interpersonal skills to work across multiple areas of the company
Excellent communications skills to accessibly articulate technical findings
Experience working with various, large-scale corporate systems and processes
Analytical capabilities, including inductive and deductive analysis to uncover relevant findings
Experience facilitating discussions and meetings across multiple functions
Change management and stakeholder management skills and experience
Desire to continuously learn and explore for personal and organizational development
Natural curiosity about an ever-evolving global risk landscape
Passion for next-generation, pro-active insurance

Senior Analyst, Bodily Injury Claims Resume Examples & Samples

Lead financial analysis of calendar and accident year trends leading to actionable insights
Identify and analyze key drivers of operational trends countrywide & at office/state level
Build financial and operational forecasts as well as descriptive models
Partner with Process & Field teams to identify, quantify, and implement process improvements
Manage moderate to complex projects
Present to senior leaders and engage across all levels of management
Perform ad-hoc analyses to address emerging issues
Bachelor's Degree in industrial engineering, business, economics, or other quantitative field
Actuarial background with experience analyzing calendar and accident year trends a strong plus
Experience building forecast models and/or descriptive models
Minimum 2+ years of non-academic work experience
Proficiency querying & analyzing complex data with SAS, SQL, or other database language
Advanced proficiency with Power Point and Excel

Claims Substantiation Analyst Resume Examples & Samples

Works with minimal direction, independently design experiments, and schedules activities
Responsible for coordinating all aspects of consumer product testing
Responsible for protocol and questionnaire development
Responsible for maintaining lab equipment
Excellent organizational skills and ability to manage multiple projects required
Accountable, leads and defines scope of projects
Assists in developing solutions to a wide range of complex problems that require ingenuity and creativity
Updates supervisor on current projects on a regular basis
Utilizes good judgment and makes timely, practical, and technically sound decisions
Completes projects in a timely and effective fashion
Ability to communicate data and insights to cross functional partners
Maintains excellent documentation of results, conclusion, and next steps
Maintains a professional work relationship with Company personnel and outside individuals
Comply with all Company policies and procedures, including confidentiality

Senior Analyst, Claims Workforce Management Resume Examples & Samples

Drive innovation & continuous improvement across the team
Responsible for owning recommended tech solutions and working with IT working with IT
Design of standard work changes/ SOPs , identifying efficiency gains, industry best practices
Work with FRM and WFM to develop assignment workflows for project phases from test and learn to full deployment
Remain agile as new initiatives across APD and Property are developed to collaborate on pilots and implementing the channeling approach; responsible for delivering against KPIs
Ability to influence leadership
Partnership with the field organization to scope opportunities, design and simplify processes, manage risks, implement changes, and realize the bottom line results
Bachelor's degree in business, economics, or other quantitative field
Minimum 5 years of experience in jobs with progressive responsibility, preferably in insurance
Must have exceptional planning, organizational, analytical, decision-making and communication skills
Experience managing individuals or operations required
Excellent analytic, quantitative and problem solving skills
Proven ability to influence others