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Michael Hughes
Claim Auditor
Summary
Highly accomplished Claim Auditor with 10+ years of experience in medical claims processing and audit. Proven track record of increasing efficiency, reducing costs, and ensuring compliance. Expertise in medical terminology, coding, policy interpretation, subrogation, and negotiation. Skilled in data analytics and claim management software. Seeking a challenging role to leverage my skills and make a significant contribution to an organization.
Education
Bachelor’s degree
February 2017
Skills
- Medical Terminology
- CPT/HCPCS Coding
- ICD-10 Coding
- Insurance Policy Interpretation
- Subrogation
- Negotiation
Work Experience
Claim Auditor
- Collaborated with adjusters, agents, and insureds to gather relevant information and provide clear and concise audit reports.
- Developed and maintained strong working relationships with internal and external stakeholders to ensure consistent and transparent communication.
- Stayed abreast of industry best practices and regulatory changes by attending conferences and completing continuing education courses.
- Utilized claim management software proficiently to manage high volumes of claims and provide timely audits.
Claim Auditor
- Developed and implemented new audit procedures to streamline the claim review process, resulting in a 15% reduction in processing time.
- Utilized data analytics tools to identify and investigate potential fraudulent claims, leading to the recovery of over $1 million in improper payments.
- Conducted complex claim investigations, involving medical records review, provider interviews, and policy interpretation, to determine coverage and liability.
- Reviewed and analyzed claim documentation to assess coverage, calculate reserves, and recommend payment or denial.
Accomplishments
- Developed and implemented a new audit process that streamlined the claim review process, reducing audit time by 20% and improving accuracy.
- Improved claim investigation efficiency by automating data extraction and analysis, resulting in a 15% reduction in investigation time.
- Identified and implemented costsaving measures by analyzing claim patterns and negotiating with vendors, saving the company $500,000 annually.
- Developed and delivered training programs for new claim auditors, improving their proficiency and reducing onboarding time by 25%.
- Spearheaded a project to improve communication and collaboration between claim auditors and other departments, resulting in a 10% increase in claim resolution efficiency.
Awards
- Received a Presidents Club Award for exceeding performance goals and contributing to the teams success in resolving complex claims.
- Recognized for consistently meeting and exceeding quality and productivity standards in claim auditing.
- Awarded a Certificate of Excellence for demonstrating exceptional analytical skills and judgment in resolving highvalue claims.
- Received a Team Excellence Award for contributing to the teams success in resolving a complex and highprofile insurance fraud case.
Certificates
- Certified Professional Coder (CPC)
- Certified Coding Associate (CCA)
- Certified Medical Auditor (CMA)
- Certified Fraud Examiner (CFE)
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How To Write Resume For Claim Auditor
Quantify your accomplishments:
Use specific metrics to demonstrate the impact of your work, such as the percentage of claims processed in a certain time frame or the amount of money saved through your audit efforts.Highlight your skills and expertise:
Showcase your proficiency in medical terminology, coding, and policy interpretation. Mention any certifications or training programs you have completed.Tailor your resume to the job:
Review the job description carefully and highlight the skills and experience that are most relevant to the role.Proofread carefully:
Make sure your resume is free of errors in grammar, spelling, and punctuation.Consider using a professional resume writer:
A professional resume writer can help you create a resume that is well-written, visually appealing, and tailored to your specific career goals.
Essential Experience Highlights for a Strong Claim Auditor Resume
- Developed and implemented new audit procedures to streamline the claim review process, resulting in a 15% reduction in processing time.
- Utilized data analytics tools to identify and investigate potential fraudulent claims, leading to the recovery of over $1 million in improper payments.
- Conducted complex claim investigations, involving medical records review, provider interviews, and policy interpretation, to determine coverage and liability.
- Reviewed and analyzed claim documentation to assess coverage, calculate reserves, and recommend payment or denial.
- Collaborated with adjusters, agents, and insureds to gather relevant information and provide clear and concise audit reports.
- Developed and maintained strong working relationships with internal and external stakeholders to ensure consistent and transparent communication.
- Stayed abreast of industry best practices and regulatory changes by attending conferences and completing continuing education courses.
- Utilized claim management software proficiently to manage high volumes of claims and provide timely audits.
Frequently Asked Questions (FAQ’s) For Claim Auditor
What is the role of a Claim Auditor?
A Claim Auditor is responsible for reviewing and evaluating insurance claims to determine their validity and accuracy. They ensure that claims are processed in accordance with company policies and industry regulations, and identify and investigate potential fraud.
What are the key skills required for a Claim Auditor?
Key skills for a Claim Auditor include medical terminology, coding, policy interpretation, subrogation, negotiation, data analysis, and claim management software proficiency.
What are the career prospects for a Claim Auditor?
Claim Auditors with experience and expertise can advance to roles such as Senior Claim Auditor, Manager of Claim Audit, or Fraud Investigator.
What is the salary range for a Claim Auditor?
The salary range for a Claim Auditor varies depending on experience, location, and industry. According to Salary.com, the average salary for a Claim Auditor in the United States is between $50,000 and $75,000.
What are the educational requirements for a Claim Auditor?
Most Claim Auditors have a bachelor’s degree in a related field, such as business administration, finance, or healthcare administration.
What are the certification programs available for Claim Auditors?
There are several certification programs available for Claim Auditors, including the Certified Professional Coder (CPC) and the Certified Insurance Fraud Investigator (CIFI).