Medical Claims Processor Resume

Samantha Gray

North Highlands CA 95660

(916) 987-6543

[email protected]

In case you are interested in knowing more info on create resume, stop by Google Docs Resume, Modern Resume or Creative Resume Templates. Always prepare before you make a choice.

Job Objective

To obtain the Medical Claims Processor position within your company and provide excellent service.

Highlights of Qualifications:

  • Wide experience in data entry and medical claim processing
  • Profound knowledge of codes applicable in CPT, HCPC, Revenue and ICD-9 systems.
  • Deep knowledge of Red Book, ASC Groupings, DRGs, Health Maintenance Organization (HMO) and IPA claim payments adjudication.
  • Familiarity about rules and regulations at DMHC and CMS.
  • Proficient in submission and editing claims electronically and other on-line systems for claim processing and problem registration
  • Skilled at decision-making, effective communication, analytical and research oriented tasks.
  • Ability to process claims for surgery, radiology, lab and medicine for CMS 1500 and CMS 1450 claim forms
  • Ability to comprehend DFRs and related benefits

Professional Experience:

Medical Claims Processor

Southwest Service Administrators Inc., Atlanta, GA

August 2007 – Present

  • Engaged to input data into processing system after interpreting medical coding and knowing terminology used in medicine professions in respect to procedures and diagnoses.
  • Ensured to process assigned claim forms and inspect apt allocation of co-pays, deductibles, reimbursements and co-insurance.
  • Complied with all judgmental policies and processes to assure appropriate claim payments.
  • Provided excellent customer service to all providers, members, insurance companies and billing department.
  • Maintained written record of phone calls in system and adhered with issues as required.
  • Solved all issues related to claim adjudication and customer complaints and queries as received over telephone.
  • Researched and analyzed claim overpayments and funds requirements.

Medical Claims Processor

Benefits Administration Corp., Inc., Atlanta, GA

May 2004 – July 2007

  • Ensured to take minimum assistance for processing complex claims.
  • Researched and processed different sets of medical plans as well as benefits.
  • Replied to inquires received in written format from participants and providers in relation to medical benefits.
  • Entered medical claim related information into PCM application.
  • Evaluated claim database which had been rejected earlier.
  • Calculated apposite amount to be paid to recipient and processed crucial payment transactions accordingly.
  • Performed and managed routine follow up activities.


Bachelor’s Degree in Health Care Management

Woodbury Institute of Champlain College, Montpelier, VT