Recovery / Resolutions Analyst Resume Samples

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AB
A Barrows
Aron
Barrows
31641 Baumbach Forge
Houston
TX
+1 (555) 798 3795
31641 Baumbach Forge
Houston
TX
Phone
p +1 (555) 798 3795
Experience Experience
Los Angeles, CA
Recovery / Resolutions Analyst
Los Angeles, CA
Murazik-Beer
Los Angeles, CA
Recovery / Resolutions Analyst
  • Compile documentation and analyze the provider disputes for accuracy and completeness by providing explanations and interpretations within area of expertise
  • Identify filter management process improvement opportunities
  • Perform QA on Optum Data Management (ODM) placement of filters
  • Manage intake of RAVE requests to remove providers from FWAE review
  • Perform other duties as assigned
  • Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits
  • 2+ yrs working with claims and/or recoveryAnalyzes and investigates
Dallas, TX
Senior Recovery Resolutions Analyst
Dallas, TX
Funk-Cruickshank
Dallas, TX
Senior Recovery Resolutions Analyst
  • Generally work is self-directed and not prescribed
  • Work directly with other departments to enhance and refine assigned inventory to maximize value
  • Use pertinent data and facts to identify and solve a range of problems within area of expertise
  • Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
  • Process recovery on claims
  • Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
  • Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
present
Los Angeles, CA
Senior Recovery / Resolutions Analyst
Los Angeles, CA
Bahringer LLC
present
Los Angeles, CA
Senior Recovery / Resolutions Analyst
present
  • Participates in provider / client / network meetings, which may include provider education through written communication
  • Participates in provider/client/network meetings, which may include provider education through written communication
  • Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits information
  • Work on multiple tasks with ongoing deadlines
  • Identifies over billing patterns and trends, waste and error, and recommends providers to be flagged for review
  • Works with less structured, more complex issues
  • Generally, work is self - directed and not prescribed
Education Education
Undergraduate Degree
Undergraduate Degree
Florida International University
Undergraduate Degree
Skills Skills
  • Strong ability to multi-task and work independently
  • Ability to adjust to changing priorities
  • Ability to work in a team
  • Frequent speaking, listening using a headset, sitting, use of hands/fingers across keyboard or mouse, handling other objects, long periods working at a computer
  • Experience working independently with the ability to make decisions using critical thinking skills
  • Ability to facilitate meeting
  • Strong written and verbal communications skills
  • Good written and oral communications skills
  • Proven ability to successfully work with cross-functional teams and clients
  • Strong organizational Skills
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2 Recovery / Resolutions Analyst resume templates

1

Recovery / Resolutions Analyst Resume Examples & Samples

  • Perform investigation on tips / allegations to identify potential Fraud, Waste, Abuse, or
  • Error (i.e. internet research, review claims history on various platforms and FWAE databases), based on applicable Job Aid
  • Adjust claims as needed based on investigation performed
  • Refer tip / allegation to the appropriate internal team
  • Adhere to turn around time standards
  • Meet and maintain minimum quality and productivity standards
2

Recovery / Resolutions Analyst Resume Examples & Samples

  • Process recovery on claims
  • Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
  • 2+ yrs in healthcare industry
  • 2+ yrs working with claims and/or recoveryAnalyzes and investigates
3

Recovery / Resolutions Analyst Resume Examples & Samples

  • Knowledgeable with all controllable and non-controllable flag types and associated platforms
  • Placement, modifications and removals of all controllable and non-controllable flag types
  • Communication with claims platform personnel for flag placement
  • First point of contact for projects requests
  • Contributes to support P&P and Job Aids
  • Daily Team communication
  • Support escalations from leaders
  • Testing and implementation support
  • High School Diploma or GED
  • 2+ years of Healthcare experience
  • 3+ months of related flagging experience
  • Proficiency and knowledge in working all flag types and associated platforms
  • Proficiency with Microsoft Excel (including data entry and editing data/formatting within existing spreadsheet)
  • Quality Assurance knowledge
  • Ability to facilitate meeting
  • Ability to adjust to changing priorities
  • Strong Process and analytical thinking skills
  • Strong organizational Skills
  • Strong ability to multi-task and work independently
  • Ability to adapt to constant change
  • Proven ability to successfully work with cross-functional teams and clients
4

Recovery & Resolutions Analyst Resume Examples & Samples

  • Analyze large spreadsheet of data
  • Determine appropriate list of claims/patients that require medical records for review
  • Create medical records request letters
  • Receive and document medical records within case tracking system
  • Additional follow-up with Providers to obtain all records requested
  • Prepare case to move to Investigations teams
  • Ensure adherence to federal compliance policies, contract compliance
  • Collaboration with Clinical Investigator, Legal and Compliance for case review
  • 1+ Years of Health Insurance Claims experience
  • Intermediate or Better Proficiency with MS Word & Excel; Creating/saving documents and spreadsheets, formatting, and using formulas
  • Medicare/Medicaid program knowledge
  • Experience working in a Special Investigations Unit (SIU) involving Insurance Waste or Errors
  • Knowledge of the following Claims platforms: COSMOS; CPW; CSP; Diamond; Facets; Oxford; NICE
  • MS Excel pivot table experience is highly valued
  • Strong written, verbal, analytical, organizational, time management and problem solving skills
  • Ability to adapt in a dynamic and high-growth environment
5

Recovery / Resolutions Analyst Resume Examples & Samples

  • Investigate and pursue recoveries and payables, and file management
  • Position requires handling of escalated issues and providers in succinct and efficient manner with excellent customer service skills
  • 3+ years of computers and Windows PC applications experience (opening files, printing, file organization)
  • 3+ years experience with Microsoft Excel (Pivot Tables, manipulate data) and PowerPoint (executive summary)
  • Experience using claims platforms in the Healthcare Industry (UNET, NICE, COSMOS)
6

Senior Recovery / Resolutions Analyst Resume Examples & Samples

  • Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits information
  • Medicare claims and/or auditing experience is strongly preferred
  • Ideal candidate will have experience working with CMS PC Pricer or understand CCI edit rules
  • Ability to identify and understand the data needs of a growing organization
  • Structure and prepare analysis to support and lead decision making
  • 2+ years of experience with claims auditing and researching claims information (reviewing the claim to ensure set up correctly)
  • 1+ years of experience analyzing data
  • 3+ years of experience in healthcare
  • Experience working with medical claims platforms/processing systems
  • Basic proficiency with Microsoft Word (creating, editing, copying, and saving documents)
  • Basic proficiency with Microsoft Excel (creating, editing, copying, and saving documents)
  • Cosmos claims platform experience
  • Basic proficiency with Microsoft Access
7

Senior Recovery Resolutions Analyst Resume Examples & Samples

  • Ability to prioritize time
  • Work on multiple tasks with ongoing deadlines
  • 1+ years of experience with claims auditing and researching claims information
  • Experience using MS Excel formulas and pivot tables
  • Experience in healthcare industry
  • Knowledge of Medicaid/Medicare Reimbursement methodologies
  • 1+ year experience with claims processing systems such as CSP, FACETS, UNISON, or DIAMOND is preferred
  • 1+ year of experience analyzing data and identify cost saving opportunities
  • 2+ years experience performing financial analysis, reporting and building knowledge of statistical calculation and interpretation
8

Senior Recovery & Resolutions Analyst Resume Examples & Samples

  • Investigate and process recoveries and account payables on subrogation claims and workers’ compensation file management
  • Responsible for communicating, disputing and negotiating subrogation claims with legal entities
  • Research and Compliance of copy service requests including Legal Summons and Complaints, Subpoenas and Authorizations
  • Self-motivated, Team Player, able to work with minimal supervision and communicate effectively with patients, outside agencies / vendors
  • Must be able to multi task; handle challenging, time sensitive, sometimes stressful job responsibilities
  • 2+ years of Experience working with in the health care industry medical claims platform
  • 2+ years of experience in the area of health insurance billing, auto insurance, workers compensation, subrogation and claims / recovery
  • 2+ years of experience analyzing data and identify cost saving opportunities
  • Knowledge of Medical Terminology, claims processing systems and guidelines
  • Intermediate skills with Excel, MS Access and Word
9

Recovery / Resolutions Analyst Resume Examples & Samples

  • Manage intake of RAVE requests to remove providers from FWAE review
  • Review requests for accuracy and completeness and use data to assess the impact to savings and claim volume
  • Support removal decision making governance process
  • Request filter placement to remove providers from review
  • Perform QA on Optum Data Management (ODM) placement of filters
  • Maintain issue tracker and manage filter placement issue resolution
  • Track reductions to claim volume and savings resulting from filter placement
  • Identify filter management process improvement opportunities
10

Senior Recovery Resolutions Analyst Resume Examples & Samples

  • Audit paid claims data to identify duplicate payments or contractual, billing, and claim processing errors
  • Initiate phone calls to providers, employer groups, and other insurance companies to gather pertinent claim information, such as verification of billed charges, confirmation of services received, and coordination of benefits information
  • Work directly with other departments to enhance and refine assigned inventory to maximize value
  • Investigate and identify overpayments on all claims types, as well as assist in recovery and resolution for health plans, commercial customers, and government entities as needed
11

Recovery / Resolutions Analyst Resume Examples & Samples

  • 1+ year of experience analyzing and solving customer problems
  • Experience working with computers - Windows PC applications and Microsoft Excel – Create/Update spreadsheet
  • Experience using claims platforms such as UNET, Pulse, NICE, Facets, Diamond, etc
  • Experience working with claims and/or recovery
12

Recovery / Resolutions Analyst Resume Examples & Samples

  • 1+ years of experience analyzing and solving customer problems
  • 1+ years of experience working with computers (Windows PC applications)
  • 1+ years of Microsoft Excel experience (creating and updating spreadsheets)
  • Associate's or Bachelor's Degree or higher
  • Experience working with claims and / or recovery
13

Senior Recovery / Resolutions Analyst Resume Examples & Samples

  • The successful candidate will be part of a group of auditors deployed to investigate possible fraud, waste and abuse in Massachusetts
  • 2+ years of experience with Medicaid or other public health care payers auditing and researching claims information
  • RN or LPN, OR 2+ years of equivalent clinical experience
  • Experience with Microsoft Excel (data entry, sorting, creating / modifying spreadsheets, Vlookup, and formulas)
  • Ability to travel up to 10% of the time (only in the state of MA)
  • 1+ years of experience analyzing data and identifying cost saving opportunities
  • Knowledge of Medicaid / Medicare Reimbursement methodologies
  • Experience with Microsoft Access (create and modify queries and reports)
  • Experience working with long-term services and supports provided by Medicaid
14

Senior Recovery / Resolutions Analyst Resume Examples & Samples

  • Investigates, reviews, and provides clinical and/or coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review. This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information
  • Performs clinical coverage review of claims, which requires interpretation of state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns
  • Performs clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding & billing
  • Maintains and manages daily case review assignments, with a high emphasis on quality
  • Provides clinical support and expertise to the other investigative and analytical areas
  • Unrestricted RN/LPN (or LVN) license OR a current certified coder
  • 2+ years of ICD-9/ICD-10 and facility DRG coding experience
  • Ability to use a Windows PC with the ability to utilize multiple applications at the same time
  • Experience using Microsoft Excel with the ability to create/edit spreadsheets, use sort/filter function and perform data entry
  • Ability to work Monday through Friday, 8:00 am to 5:00 pm Central Time
  • Healthcare claims experience
  • Investigation and/or auditing experience
  • Knowledge of health insurance business, industry terminology, and regulatory guidelines
15

Recovery / Resolutions Analyst Resume Examples & Samples

  • Investigate and resolve all types of claims for health plans, commercial customers, and government entities
  • Receive and initiate phone calls to providers to gather pertinent information and documentation for review activity
  • Handle faxes and mail from healthcare providers
  • Provide education pertaining to audits
  • Compile documentation and analyze the provider disputes for accuracy and completeness by providing explanations and interpretations within area of expertise
  • Manage assigned projects, participate in dispute hearings and administrative hearings
16

Recovery / Resolutions Analyst Telecommute Resume Examples & Samples

  • Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits
  • 1+ years of Customer Service experience
  • 1+ years’ experience using claims platforms such as COSMOS, CSP, UNET, Pulse, NICE, Facets, Diamond, etc
  • Ability to use Microsoft Excel for data entry and manipulate data to upload reports
  • Ability to use Microsoft Word to generate professional documentation
  • Ability to use Microsoft Outlook to manage emails and send professional communication
  • Experience working in the Healthcare industry
  • Experience working with Claims and/ or Recovery
  • Experience working with LBWS and ODAR
  • Working experience with processing C&S, M&R or E&I refunds
17

Senior Recovery / Resolutions Analyst Resume Examples & Samples

  • Production related activities
  • Ability to navigate PC based software
  • CPT & ICD coding experience
  • Experience with health insurance billing / coding
  • Experience working with Windows PC software - Microsoft Office: Excel - (Creating / Managing spreadsheets, formulas, pivot tables), Word – (Creating / Managing documents)
18

Senior Recovery / Resolutions Analyst Resume Examples & Samples

  • Performs clinical coverage review of post-service, pre-payment claims, which requires interpretation of state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with over billing patterns
  • Participates in training of new staff, and serves as a clinical resource to other areas within the clinical investigative team
  • 4+ years of RN, LPN current experience with an unrestricted license, OR 4+ years experience as a Certified Coder AHIMA or AAPC Certified, CPC, CCS, RHIT, CPMA, RHIA, OR 4+ years of CPT/HCPCS/ICD-9 or 10 coding experience with knowledge of health insurance business, including knowledge of industry terminology, and regulatory guidelines
  • Healthcare Claims experience
  • Investigational and / or Auditing experience
19

Senior Recovery / Resolutions Analyst Resume Examples & Samples

  • Performs clinical coverage review of post-service, pre-payment claims, which requires interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with over billing patterns
  • Participates in provider / client / network meetings, which may include provider education through written communication
  • 4+ years of RN, LPN current experience with an unrestricted license, OR 4+ years of experience as a Certified Coder AHIMA or AAPC Certified, CPC, CCS, RHIT, CPMA, RHIA, OR 4+ years of CPT / HCPCS / ICD-9 or 10 coding experience with knowledge of health insurance business, including knowledge of industry terminology, and regulatory guidelines
  • Ability to Navigate PC based software
20

Recovery Resolutions Analyst Resume Examples & Samples

  • Document in a professional manner the investigation activities that were performed on tips and allegations
  • Submit CMS reporting as required
  • Ensure adherence to state and federal compliance policies and reimbursement policies
  • Associates Degree (or higher) or High School Diploma/GED with 3+ years of insurance or fraud investigation experience
  • Ability to use Microsoft Excel (create pivot tables)
  • 2+ years of experience in criminal justice, legal or fraud investigation
  • Experience in working with claims platforms
  • Professional Certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
  • Experience utilizing interpersonal skills: objective, collaborative approach
  • Experience working independently with the ability to make decisions using critical thinking skills
21

Senior Recovery / Resolutions Analyst Resume Examples & Samples

  • Perform investigation on tips / allegations to identify potential Fraud, Waste, Abuse, or Error (i.e. internet research, review claims history on various platforms and FWAE databases), based on applicable Job Aid
  • Perform member and provider interviews, and review medical documentation as needed
  • Document in a professional manner the investigation activities that were performed on tips / allegations
  • Communicate with clients and business partners as needed
  • Sought out as an expert
  • Train / mentor less experienced team members
  • Audit work of new team members and educate based on results
  • Handle more complex tasks (e.g. medical record review, C&S clients, escalations, special requests from other departments)
  • 2+ years in criminal justice, legal or fraud investigation
  • Experience working in claims systems / platforms
  • Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI) or similar
  • Experience in solving complex problems by utilizing computer research
  • Excellent interpersonal communication abilities
  • Ability to work independently with minimal direction, as well as work well within a team environment
22

Recovery Resolutions Analyst Resume Examples & Samples

  • Document in accordance with investigative standards, all investigative activity and findings in proprietary database
  • Communicate claim processing instruction
  • Ability to work in a production environment and meet required production and quality standards
  • Strong analytic and problem solving skill
  • Possess the ability to work in a team environment
  • 1+ years of claims experience (processing, research or adjustments)
  • Ability to navigate Microsoft Office Applications: Microsoft Word (ability to create / edit document); Microsoft Excel (VLOOKUP and formulas)
  • Experience working in the healthcare industry
  • Associate’s Degree or higher
  • 1+ years of claims operations experience
  • Experience using claims platforms such as COSMOS, CPW, NICE, Facets
23

Recovery / Resolutions Analyst Resume Examples & Samples

  • High School Diploma / GED (or higher)
  • 1+ years of experience working with computers (Windows PC applications), multiple screens
  • Associate's or Bachelor's Degree (or higher)
24

Recovery Resolutions Analyst Resume Examples & Samples

  • Associate's Degree (or higher) or High School Diploma / GED with 3+ years of insurance or fraud investigation experience
  • 2+ years of Insurance experience with one or more of the following: Claim Processing, Provider Demographic Information, or Insurance Billing Practices
  • 2+ years of experience in criminal justice, legal, or fraud investigation
25

Senior Recovery / Resolutions Analyst Resume Examples & Samples

  • Generally, work is self - directed and not prescribed
  • Ability to work within standard business hours Monday-Friday. Overtime will be available occasionally
  • Licensed Registered Nurse (RN), Licensed Practical Nurse (LPN) or Certified Coder (CPC, RHIT, and/or CCS)