Medical Claims Examiner Resume Sample

15 votes

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Johnathon Flatley
690 Selina Shore,  Phoenix, AZ
+1 (555) 361 5950

Work Experience

Medical Claims Examiner
07/2017 - PRESENT
Houston, TX
  • Provides data to Case Management Team members and assists in the development of a treatment and return to work plan, when applicable
  • Provide excellent service to all stakeholders, including timely and professional response to all inquiries and calls, appropriate explanation of process and/or benefits with appropriate messaging in the appropriate manner
  • Responsible for compliance with all Workers’ Compensation laws, rules and regulations including timely EDI and compliance reporting requirements and resolution of any EDI and/or compliance issues
  • Responsible for each case’s compliance with established service standards and procedures including medical only claims adjusting best practices
  • Organizes workload so that all cases receive the proper claims handling and are promptly brought to a conclusion
  • Understands and works within PERMA’s core beliefs
  • Takes a proactive approach to office safety and ergonomics and adheres to all safety policies
  • Attends orientations of new Members assigned to them and makes Member visits on an “as needed” basis
Medical Claims Examiner
07/2014 - 05/2017
Dallas, TX
  • Our work-at-home assignments require high speed internet services (non-refundable) and we provide a PC for the duration of the project
  • Batch and prioritize claims processing utilizing the Company’s in-house claims processing system
  • Verify patient’s accounts for eligibility and benefits
  • Process complex claims that have been accepted for payment
  • Request and follow-up on additional information as needed for incomplete claims
  • Complete all steps above within designated timeframes (production quotas) and notify management if claims cannot be processed within the designated time frame
  • Assemble denial letter background information and generate denial letters
  • Read, interpret and summarize medical contracts / division of responsibility


Indiana Wesleyan University - Kokomo Campus
2009 - 2014
Bachelor's Degree in Computer

Professional Skills

  • Demonstrates excellent interpersonal skills as discerned through observation and team project successes
  • Strong customer service, analytical and problem-solving skills
  • Experience working on claims in a managed care setting
  • Experience of Institutional Claims processing
  • Experience working with various fee schedules (i.e., CMS, Medical, etc.)
  • Strong proficiency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications
  • Efficiently organizes and prioritizes workflow

How to write Medical Claims Examiner Resume

Medical Claims Examiner role is responsible for travel, events, compensation, reporting, insurance, messaging, ergonomics, health, contracts, benefits.
To write great resume for medical claims examiner job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Medical Claims Examiner Resume

The section contact information is important in your medical claims examiner 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
  • Email
  • Telephone number

Work Experience in Your Medical Claims Examiner Resume

The section work experience is an essential part of your medical claims examiner 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 medical claims examiner responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular medical claims examiner position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Medical Claims Examiner resume experience can include:

  • Have a general understanding of all E & O liabilities and keep current and accurate documentation to support claims paying practices
  • Accurately interprets and applies departmental policies and procedures using sound judgment as is related to claims processing
  • Review claims that are pending and follows through for payment in a timely manner
  • Have a general understanding of all legislative requirements and is able to take direction to meet those requirements in a prudent business manner
  • Adapt to a changing environment
  • Identify claims that are not our financial risk and forward to appropriate entity for payment

Education on a Medical Claims Examiner Resume

Make sure to make education a priority on your medical claims examiner resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your medical claims examiner 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 Medical Claims Examiner Resume

When listing skills on your medical claims examiner 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 medical claims examiner skills:

  • Demonstrates overall professionalism in attitude, demeanor and personal appearance
  • Contract and DOFR interpretation experience
  • Experience as a Medical Claims Examiner
  • Workers Compensation Claims experience
  • Strong proficiency with computer and Windows PC applications, which includes the ability to learn new computer system applications
  • Covering for Supervisor at times

List of Typical Skills For a Medical Claims Examiner Resume


Skills For Medical Claims Examiner Resume

  • Communicates clearly, professionally and respectfully to peers, superiors, subordinates and clients
  • Meets production quota for both input levels and accuracy on a weekly basis as set forth by the department standards
  • Provides constructive feedback on work projects assigned
  • Consistently produces accurate and timely work product as it relates to departmental goals
  • In a Workers Compensation Future Medical/MWorkers Compensation Claims Assistant role

Skills For Medical Claims Examiner Resume

  • Licenses/Certifications: Independent Adjuster’s License
  • Treat peers, superiors, subordinates clients and vendors with fairness, courtesy and professionalism and contribute to the overall positive work environment of the department
  • Complete other production projects as assigned
  • Authorize medical treatment, physical therapy and medications as directed in the instructions placed in the file
  • Investigate, manage, and resolve simple medical claims

Skills For Medical Claims Examiner Resume

  • Monitor regulatory compliance to ensure such requirements are met within defined parameters
  • Maintains a license for all states and products serviced as required
  • Organize and update all reference material to reflect current legislation and regulatory compliance
  • Comply with all quality control standards set by the company for the handling of claims. Comply with all procedures set forth by the company for performing the job as it relates to the various components of claim administrative services
  • Immediately notify Management of any unusual lawyer inquiries, insurance carrier inquiries, or department of insurance inquiries
  • Read, interpret and summarize medical contracts/division of responsibility

Skills For Medical Claims Examiner Resume

  • Request and follow - up on additional information as needed for incomplete claims
  • Read, interpret and summarize medical contracts/division of responsibility before allowance of payments
  • Works with various fee schedules (i.e., CMS, Medical)
  • Self Insured Certificate

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