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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical claims processing and adjudication, with a strong understanding of medical coding, insurance verification, and compliance with healthcare regulations. Proven ability to meet production standards while effectively resolving claims appeals and conducting thorough claims research.
Highest-signal resume keywords
Medical Claims ProcessingClaims AdjudicationMedical CodingCPT and ICD10 KnowledgeHealthcare Industry Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ProcessingClaims ResearchInsurance VerificationMedical Necessity InterpretationClaims InvestigationsNegotiation of SettlementsClaims Appeals ResolutionFinancial History CorrectionBenefit ResearchPlan Loading Verification
Soft Skills
Attention to DetailProblem SolvingCommunication
Certifications & Qualifications
High School DiplomaGED
Industry Keywords
HIPAACOBRACoordination of BenefitsPre-existing ConditionsSurgical Procedures
About the role
Key responsibilities & impact- Process claims daily for accounts
- Process medical, dental, vision, and mental health claims
- Perform claims processing and adjudication
- Conduct claims research where applicable
- Review and process insurance to verify medical necessity and coverage under policy guidelines using clinical edit logic
- Meet and/or exceed qualitative and quantitative production standards
- Facilitate claims investigations
- Negotiate settlements
- Interpret medical records
- Respond to Department of Insurance complaints
- Authorize payments to claimants and providers
- Review and recover claim overpayments
- Correct financial histories of patients and service providers
- Track complaints and resolutions using relevant systems
- Resolve claims appeals
- Research benefits
- Verify correct plan loading
Requirements
What you’ll need- 2+ years related work experience
- Medical claims and adjudication experience on a computerized claims payment system in the healthcare industry
- High school diploma or GED
- Knowledge of medical coding, CPT, ICD10, COBRA, HIPAA, pre-existing conditions, and coordination of benefits
- Experience with multiple surgical procedures and establishment of reasonable and customary fees
- Experience processing all types of medical claims is helpful
- Medical billing and coding courses are a plus
Benefits
Comp & perks- Medical, dental, vision, life and global travel health insurance
- Life insurance
- Short- and long-term disability programs
- Leave programs to support personal circumstances
- Retirement Savings Plan with employer contribution and employer match
- Paid time off
- Volunteer time off
- 11 holidays
- Additional voluntary benefits
- Comprehensive wellness program