Claims Auditor Resume Sample
Ceasar Hegmann
40881 Pouros Street,
San Francisco,
CA
+1 (555) 449 7053
Work Experience
Claims Auditor Team Lead
04/2016
-
PRESENT
Dallas, TX
- Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer
- Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
- Conduct reviews of claims coding and benefit payments to identify errors in processing and payment and to ensure claims are settled according to company policies and procedures
- Conduct accuracy and/or timeliness reviews in the areas of claims, inquiries, or enrollment to determine whether work was performed accurately and within specified timeframes
- Research cause of errors to determine origin. Prepare audit report findings for management review and other stakeholders
- Recommend process improvements to drive issue resolution. Collaborate with internal areas to implement process changes
- Participate on department initiatives and projects
- At least three (3) years’ experience in customer/client service, account management, or business development disciplines
Claims Auditor
03/2009
-
02/2016
San Francisco, CA
- High proficiency in Microsoft Excel and Microsoft Office applications (Specifically OneNote and SharePoint)
- Able to communicate effectively with all levels of staff and customers
- Review a percentage of claims in the SQA/RRI Mailroom module for accuracy in accordance with applicable policies on a daily basis
- Provide professional, accurate and appropriate feedback to claims processors via the client audit database documentation system
- Maintain valid adjuster’s license in home state or in areas as jurisdictionally required
- Relevant Work Experience: Relevant claims processing experience, preferably in a health care environment
- Knowledge, Skills & Abilities: Strong written and verbal communication skills
- Evaluates high dollar claims for accuracy and completeness
Construction Claims Auditor
11/2002
-
02/2009
San Francisco, CA
- Obtains facts to evaluate contract coverage
- Provides timely contact with all required parties
- Maintains quality claim files in accordance with appropriate best practices and claim handling file expectations
- Communicate effectively with clients and co-workers
- Be flexible and adaptable in a fast paced, team environment
- Work independently and use intuitive decision making
- Expert proficiency with Microsoft Excel
- Handle urgent and sometimes difficult calls
Education
University of Northern Virginia
1996 - 2001
Bachelor's Degree in Business Administration
Professional Skills
- General accounting, financial & business skills, knowledge, & experience
- Excellent verbal & written communication & presentation skills
- Demonstrates effective communication, interpersonal, and organizational skills
- Basic project management skills
- Three years’ experience with health insurance operational or compliance audits or related experience in the healthcare or financial services industry
- Working knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines
- Agreeing pragmatic management actions for reportable issues, making clear, achievable recommendations, adequately prioritised to meet business objectives
How to write Claims Auditor Resume
Claims Auditor role is responsible for government, software, mainframe, finance, training, database, auditing, reporting, education, research.
To write great resume for claims auditor job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Claims Auditor Resume
The section contact information is important in your claims auditor resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Claims Auditor Resume
The section work experience is an essential part of your claims auditor resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous claims auditor responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular claims auditor position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Claims Auditor resume experience can include:
- Insurance auto claims experience including claims adjusting, claims auditing and/or claims supervision
- Experience in liaising and reporting to senior management
- Develop and maintains good working relationships
- Recent experience utilizing MS Word, Excel, and PowerPoint
- Recent experience utilizing MS Access
- Experience in claims auditing
Education on a Claims Auditor Resume
Make sure to make education a priority on your claims auditor resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your claims auditor experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Claims Auditor Resume
When listing skills on your claims auditor resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical claims auditor skills:
- Effectively utilize general audit software such as ACL, TeamMate, etc
- Skilled presenter with excellent written and oral communication
- Designing and executing appropriate testing strategies to provide a robust opinion on the design and operating effectiveness of the controls
- Identifying the key risks, controls and opportunities to improve operating efficiency or effectiveness, in order to minimise the cost of claims handling
- Developing a good knowledge of the audit area under review
- Over 5 years and up to and including 7 years of experience in an indemnity and / or HMO setting processing, auditing or adjusting professional claims
List of Typical Experience For a Claims Auditor Resume
1
Experience For Claims Auditor Team Lead Resume
- Document using narrative and/or flowcharting techniques
- Act as a reference point for Trainee Auditors, assisting with quality assurance and supporting individual development
- To maintain current knowledge of all legal & market practice issues affecting claims handling
- Reports and tracks audit findings, summarizes problem areas, and identifies potential solutions, remedies, and controls
- Analyze problems and communicate results
- Conduct quality assurance audits adjustments, refunds & provider disputes. Review each claim image to the actual data input into the system & claim payment to ensure accuracy
- The position requires research, problem resolution & specialized knowledge in the areas of contracts, Medicare & Medi-Cal regulations & reimbursement rules, Multiplan & Beech Street, Worker's Compensation, Coordination of Benefits & Third Party liability
- Responsible for conducting audit testing and completing documentation of the work performed for audit in diverse disciplines
2
Experience For Senior Claims Auditor Resume
- Develop work papers that address the objectives of the audit program and support the conclusions reached during testing. Adhere to the IIA Standards and IAS guidelines for workpaper documentation
- Assess business systems/processes to identify key control points and risks
- Draft audit conclusions, discuss potential issues with clients, and prepare and deliver other summary communication documents
- Support the assigned practice area team
- Responsible for ensuring the accuracy of claims payments with the application of managed care contracts, as well as reimbursement calculation of applicable fee schedules for non-contracted claims
3
Experience For Claims Auditor Specialist, Senior Resume
- Identifies underpayments/overpayments and generates periodic reports to quantify amounts detected through the audit process
- Communicates errors to Compliance Supervisor and trends errors for corrective actions
- Audits member liability denials to assure quality of claim determinations and ensures compliance with health plan requirements
- Audits PDR appeals to assure the quality of the letters generated and the accuracy of the data loaded into the Provider Dispute database
- Conducts detail audits for compliance with State, Federal and Health Plan regulatory requirements
- Conducts pre-and post payment audits on adjudicated claims in compliance with Cedar-Sinai policies, procedures and payment methodologies
- Documents audit findings and researches errors to determine root cause and makes recommendations for appropriate resolution
- Provides analysis and prepares recommendations to Management for errors and inconsistences
4
Experience For Construction Claims Auditor Resume
- Provides process improvement suggestions to Management
- Monitors appeals from providers, members and health plans to make sure they are processed accurately and in timely manner
- Distribute and monitor multiple projects to make sure deadlines are met
- Process all check issues
- Has the ability to function both independently & as a team member
- Ensures compliance with functional policies and procedures prescribed by management
- Interprets and carries out general guidelines
5
Experience For HRA Claims Auditor Resume
- Interacts regularly with various Regional management, Internal Audit management & staff, external auditors & consultants
- Typically receives general direction on routine work and detailed direction on new assignments
- Determine if claim amount is correct. Decide if claim needs to be challenged
- Review Client Plan Document to assist in appeal of claim denial, if applicable
- Examines claim reports to determine extent of coverage and liability
- Communicate to Sales staff of any denials and/or disclosure issues
6
Experience For Medicare Claims Auditor Resume
- Maintain and analyze Claims/Payment log on a daily basis
- Maintain and update Loss Ratio Report on a monthly basis
- Compile and review any other necessary reports as needed
- Deliver and document audit work to in-house standards and methodology
- Using knowledge of the business and risk throughout the audit process to ensure that the significant issues are identified, and reported with authority and credibility
- Build and manage the relationships with business management during the audit process and on a day-to-day basis as required
7
Experience For Claims Auditor, Snr Resume
- Report upwards to the Business Assurance Manager, keeping them up to date on the progress of audits, and any significant issues that have been highlighted during audit work or through discussions with management
- Work alongside the relevant claims management team to ensure all audit recommendations and actions are implemented in a timely and effective manner ensuring delivery to the required standard
- Support the business with the due diligence process in relation to prospective suppliers
- Conducts pre and post payment claim audits on adjudicated medical claims to ensure claims are processed in accordance with hospital/provider contracts, member plan benefits, compliance, and company policies and procedures
- Conducts pre and post adjustment/PDR/reopening audits in accordance with compliance and company policies and procedures
8
Experience For Senior External Claims Auditor Resume
- Conducts claim code audits and make necessary corrections according to recommendations, compliance, and company policies and procedures
- Compiles error data including underpayments/overpayments to generate periodic reports
- Communicates errors to examiners daily
- Works with supervisor and manager to identify error trends and provide recommendations to fix claims issues
- Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows. Assigned to handle second level review for high dollar claims prior to release of payment. Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer
- Assist Claims Trainer with analyzing Claim error trends. Also serves as the primary back up for the Trainer in regards to Claims Change Form requests from the Contracting department
- Analyze and prepare Health plan claims selections for Annual health plan audit. Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor are present at the time of audit
- Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests. Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines
- Mostly sedentary work
List of Typical Skills For a Claims Auditor Resume
1
Skills For Claims Auditor Team Lead Resume
- Insurance claims experience including claims adjusting, claims auditing and/or claims supervision
- Strong working knowledge of associated Department of Managed Health Care and health plan requirements
- Claims processing experience
- Three (3) or more years of experience in claims processing and claims audit functions
- Identifies ethical issues and discusses them in a timely and constructive manner to obtain a rapid and effective resolution
- Medical Claims experience
- Strong understanding of CPT, ICD9, HCPCS, medical terminology, COB COBRA, and FMLA
- Demonstrable experience within an auditing or assurance role would be advantageous
- A good standard of secondary education is necessary
2
Skills For Senior Claims Auditor Resume
- A great communicator. Can form a rapport with people at all levels of the business. Listens to others, and demonstrates that they have listened
- Effective self-motivator and networker
- Good standard in Word and Excel
- Experience of qualitative assessment in a large scale operation
- Review and Interpret stop loss claim submissions for disclosure and accuracy of information prior to carrier submission
3
Skills For Claims Auditor Specialist, Senior Resume
- Review claim payments/denials for accuracy prior to communication to Administrator
- Understanding of claim adjudication, member benefits and/or quality program protocols
- Drafting audit issues and the full audit report to a high standard
- Has an enquiring mind and tenacity, whilst maintaining objectivity
- Demonstrable competence in analysing and assessing risk and control frameworks
4
Skills For Construction Claims Auditor Resume
- Adapt in a fast moving and constantly changing organisation
- Perform daily audits by analysis / Investigation of medical claims data to identify incorrect coding, waste, overpayments, and processing errors of claims
- Interfaces with various health care delivery systems to ensure on-time and accurate claim processing and servicing activities
- Adapt quickly to changing demands & environment, & rapidly develop in-depth knowledge of new audit areas
- Computer literacy on PC based software programs, including Microsoft Excel & Word
- The ability to see the job through within agreed time frames, working mainly autonomously but sometimes as part of a team
- Reviews error trends in processing and keep IS informed for system update
- Monitors the daily auditing of processed claims and letters for accuracy
- Responsibilities typically include cost containment, retiree coverage, negotiating with managed care providers, and wellness programs
5
Skills For HRA Claims Auditor Resume
- Timely communication to Carrier or Administrator regarding request of additional information needed to process claim
- Provide and assist sales staff with monthly renewal claim reporting as needed
- Process large claim notifications, including notification to sales staff of any possible disclosure concerns
- Process Aggregate Reports, including notification to sales staff of any potential aggregate claim
- Microsoft Office (Word, Excel, PowerPoint & Access)
- Sets the tone for ethical behavior, actively models ethical behavior to set an example for others
- Does not tolerate a breach of ethics in others
- Proficient in medical terminology and the use of ICD-9/ICD-10, CPT, HCPCS and DRG’s
6
Skills For Medicare Claims Auditor Resume
- Knowledge of DOFR’s (Division Of Financial Risk), newborn guidelines and AB1455
- Understands and interprets Health Plan Division of Financial Responsibility (DOFR)
- Background in Managed Care industry
- Comprehensive knowledge of ICD-9, CPT, and HCPCS codes, medical terminology, and COB
- Comprehensive knowledge of various fee schedules – DRG, APC, ASC, RBRVS
- IIA/CPCU designations are desirable
- Acquire and perform progressively more complex skills and tasks in a production environment or any combination of education and experience, which would provide an equivalent background
- Strong working knowledge of reinsurance and claims processing
- A clear understanding of current Claim Departments processes and procedures
7
Skills For Claims Auditor, Snr Resume
- Quickly gets to grips with understanding new businesses, process or products. Able to logically analyse and assess these
- Is not intimidated by challenging or senior individuals in the business. Has the courage of their conviction
- A person with a positive outlook, who is flexible and quickly adapts to the changing needs of the business and the objectives of the department
- Knowledge of the principles of property and casualty insurance and the auto claims adjustment process
- Sound use of judgement. Raises and reports only material issues, and is able to agree practical and efficient solutions with the business
- Has the highest level of integrity, and is seen to uphold the standards and policies set by the department and the Group at all time
- Keeps sensitive business or department information secure and confidential, without exception
- Light physical effort (lift up to 10lbs)
8
Skills For Senior External Claims Auditor Resume
- Certified Professional Coder through AAPC or AHIMA
- Provides feedback on processing errors; identifies quality improvement opportunities and initiates basic requests related to coding or system issues, where applicable
- Knowledge of claims best practice, current industry standards and relevant legislation
- Analyse complex and diverse situations
- Use own initiative to generate solutions for the business and associated third parties
- Solid understanding of MetLife claims review processes and work flows; ensuring consistency while conducting audit in alignment with MetLife claims policies & procedures, business rules, and guidelines
- Review internal claims data/reports to analyze provider performance and thereby to detect and prevent incorrect coding, abuse and fraudulent billing practices to keep claims cost control
- Prepare claims samples and supporting documentation for the on-site review and to conduct on-site provider claims & quality audit to ensure proper coding & billing practices and compliance to contractual obligations
9
Skills For Delegated Claims Auditor Resume
- Confers with management to assess training needs in response to changes in policies, procedures, regulations, and technologies
- Performs the CCS Claims Appeals functions including claims audits, high dollar review, contract compliance, and response narratives
- Obtains samples and audits the use of the most up to date provider contracts, fee tables, and other reference data used in the claims processing functions
- Identifies aberrant patterns of billing and detects potential abuse through paid claims data analysis
- Maintain consistent and quality production standards with consideration around specific audit and turnaround expectations
- Collaborate, coordinate, and communicate across departments and stakeholders
- Ensure compliance with local regulatory requirements and regulations
10
Skills For Senior Delegated Claims Auditor Resume
- Identifies and escalates issues related to instructional material that is inaccurate, unclear or contains gaps
- Provides recommendations for correction of this material
- Ensures financial and administrative controls are maintained to ensure accurate and timely payment of authorized claims
- Ensures compliance with CCS’s claims standards, audit criteria, and other policies and procedures
- Understands and references CCS provider contracts, leased network contracts, and other relevant artifacts as they relate to claims audit and appeals
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