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Leroy Martinez
Medical Claims Examiner
Summary
Highly skilled and experienced Medical Claims Examiner with a proven track record of analyzing medical claims, identifying potential fraud and abuse, and ensuring accurate and timely adjudication. Proficient in medical terminology, CPT and ICD-10 coding, policy interpretation, and utilization review. Excellent communication and interpersonal skills, with a strong work ethic and attention to detail. Committed to delivering exceptional customer service while maintaining compliance with insurance regulations.
Education
Bachelor’s in Health Administration
July 2019
Skills
- Medical Terminology
- CPT and ICD-10 Coding
- Claims Processing and Adjudication
- Policy Interpretation and Coverage Determination
- Utilization Review and Case Management
- Fraud, Waste, and Abuse Detection
Work Experience
Medical Claims Examiner
- Applied knowledge of insurance policies and procedures to ensure accurate and timely adjudication of claims.
- Processed a high volume of claims efficiently and accurately, meeting established performance targets.
- Reviewed medical records, treatment plans, and other documentation to assess claim validity and determine appropriate payment.
- Utilized claims processing software to enter, track, and manage claim information.
Medical Claims Examiner
- Analyzed medical claims to verify accuracy and compliance with insurance regulations, identifying potential fraud and abuse.
- Investigated claims discrepancies and resolved issues promptly, communicating findings to both providers and members.
- Utilized medical terminology and coding knowledge to determine appropriate reimbursement and coverage.
- Collaborated with healthcare providers to clarify medical documentation and obtain necessary information for claim processing.
Accomplishments
- N/A due to security regulations
Awards
- N/A due to security regulations
Certificates
- Certified Medical Claims Specialist (CMCS)
- Certified Professional Medical Auditor (CPMA)
- Registered Health Information Administrator (RHIA)
- Certified Coding Specialist (CCS)
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How To Write Resume For Medical Claims Examiner
- Highlight your knowledge of medical terminology, coding, and insurance regulations.
- Quantify your accomplishments with specific metrics and results.
- Showcase your ability to work independently and as part of a team.
- Emphasize your commitment to accuracy and customer service.
Essential Experience Highlights for a Strong Medical Claims Examiner Resume
- Analyze medical claims for accuracy, completeness, and compliance with insurance regulations.
- Investigate claim discrepancies and resolve issues promptly, communicating findings to both providers and members.
- Utilize medical terminology and coding knowledge to determine appropriate reimbursement and coverage.
- Collaborate with healthcare providers to clarify medical documentation and obtain necessary information for claim processing.
- Apply knowledge of insurance policies and procedures to ensure accurate and timely adjudication of claims.
- Review medical records, treatment plans, and other documentation to assess claim validity and determine appropriate payment.
Frequently Asked Questions (FAQ’s) For Medical Claims Examiner
What is the role of a Medical Claims Examiner?
A Medical Claims Examiner reviews and analyzes medical claims to ensure they are accurate, complete, and compliant with insurance regulations. They also investigate discrepancies and resolve issues with providers and members.
What skills are required to be a Medical Claims Examiner?
A Medical Claims Examiner typically needs a combination of medical knowledge, coding skills, and insurance expertise. They should also have strong communication and interpersonal skills.
What is the job outlook for Medical Claims Examiners?
The job outlook for Medical Claims Examiners is expected to grow faster than average in the coming years due to the increasing demand for healthcare services.
What is the salary range for Medical Claims Examiners?
The salary range for Medical Claims Examiners varies depending on experience, location, and employer. However, the median annual salary is around $55,000.
What are the career advancement opportunities for Medical Claims Examiners?
Medical Claims Examiners can advance to positions such as Claims Supervisor, Claims Manager, or Director of Claims.
What are the challenges of being a Medical Claims Examiner?
Medical Claims Examiners can face challenges such as dealing with complex medical information, working under tight deadlines, and resolving disputes with providers and members.
What are the rewards of being a Medical Claims Examiner?
Medical Claims Examiners can find rewards in helping to ensure that patients receive the benefits they are entitled to, protecting insurance companies from fraud and abuse, and contributing to the overall efficiency of the healthcare system.