I have over three years of experience in healthcare claims processing, primarily with a large insurance company. During this time, I have handled a variety of claims, from initial submissions to complex appeals. I am proficient in using claims processing software such as ClaimCenter and have a strong understanding of CMS guidelines and HIPAA regulations. My experience has equipped me with the skills to efficiently manage and resolve claims issues, ensuring timely and accurate processing.

Ensuring accuracy and compliance is paramount in claims processing. I meticulously review each claim for completeness and adherence to coding standards, such as ICD-10 and CPT codes. I stay updated with the latest regulatory changes and company policies to maintain compliance. By double-checking all details and cross-referencing with provider contracts, I minimize errors and prevent potential fraud. This meticulous approach ensures that every claim is processed correctly and in accordance with industry standards.

Handling high-volume claims requires efficient time management and prioritization skills. I prioritize claims based on urgency and complexity, ensuring that critical cases are addressed promptly. I utilize batch processing techniques to handle routine claims simultaneously, which saves time without compromising accuracy. Additionally, I maintain open communication with the healthcare providers to expedite the resolution of any discrepancies, thereby streamlining the overall process and enhancing productivity.

Resolving disputes or denials involves a detailed analysis of the claim and the reason for denial. I first ensure that all necessary documentation is in order and that the claim complies with coverage rules. If a dispute arises, I engage in constructive dialogue with providers to understand their perspective and find a mutually agreeable solution. I also prepare comprehensive appeal letters, providing clear evidence and rationale for reconsideration. My goal is to resolve issues efficiently while maintaining positive relationships with providers.

One challenging claim involved a complex surgical procedure with multiple billing errors and a denied claim. I began by thoroughly reviewing the medical records and coding to identify the discrepancies. I then coordinated with the provider to correct the coding and resubmit the claim. After the resubmission, I followed up diligently, addressing additional queries from the insurer. Through persistent communication and meticulous documentation, I successfully overturned the denial, ensuring the patient received the necessary coverage.