Medical Claims Analyst Resume Example

Senior Medical Claims Analyst · Optum (UnitedHealth Group)

Chicago, IL · 2020 - Present

• Led complex claims adjudication for high-value Medicare and Medicaid cases, resolving an average of 150+ claims weekly with a 98% accuracy rate.
• Identified and investigated payment integrity issues, recovering over $1.2 million in potential overpayments by analyzing claim patterns and applying CMS guidelines.
• Collaborated with cross-functional teams to streamline appeals processes, reducing appeal resolution time by 20% and improving member satisfaction scores.
• Conducted monthly audits of claims processing to ensure compliance with HIPAA, HITECH, and internal payer policies, consistently maintaining a >95% compliance rate.
• Mentored junior analysts on advanced claims processing techniques and regulatory changes, enhancing team efficiency and reducing training cycle time by 15%.

Medical Claims Analyst · Meridian Health Plan

Chicago, IL · 2018 - 2020

• Processed an average of 200+ medical claims daily for commercial and government-sponsored health plans, adhering to strict turnaround times and quality standards.
• Reviewed and resolved claim denials, successfully overturning 90% of appealed claims through thorough documentation and policy application.
• Contributed to a 10% reduction in claims processing errors by proactively identifying root causes of common discrepancies and proposing system enhancements.
• Utilized claims processing software to verify member eligibility, provider network status, and benefit coverage for accurate adjudication.
• Assisted in quarterly internal audits, contributing to a 5% improvement in overall claims accuracy for the department.

Bachelor of Science in Health Information Management · University of Illinois Chicago (UIC)

Chicago, IL · 2014 - 2018

• Graduated with Honors, Cum Laude
• GPA: 3.7/4.0
• Relevant Coursework: Medical Billing & Coding, Healthcare Law & Ethics, Healthcare Data Analytics

Medical Claims Analyst · Blue Cross Blue Shield of Illinois

Chicago, IL · 2021 - Present

• Adjudicated an average of 150 complex medical claims daily, achieving a 98% accuracy rate against industry benchmarks and reducing processing backlog by 20%.
• Identified and resolved billing discrepancies totaling over $500,000 annually through meticulous review of patient records and coding guidelines (ICD-10, CPT).
• Collaborated with providers to clarify documentation and resolve claim denials, resulting in a 15% reduction in re-submission rates.
• Contributed to a cross-functional task force that enhanced fraud detection protocols, leading to the identification of $1.2M in potential fraudulent claims in Q4 2022.

Financial Analyst · Abbott Laboratories

Lake Bluff, IL · 2018 - 2021

• Analyzed quarterly financial data for the medical device division, identifying trends and variances that led to a 10% improvement in budget forecasting accuracy.
• Developed and maintained complex Excel models to track departmental expenses, reducing reporting time by 15 hours per month.
• Ensured compliance with internal financial policies and external regulations, contributing to successful audit outcomes for 3 consecutive years.
• Presented financial insights to senior management, supporting strategic decision-making for product launches and market entry strategies.

Bachelor of Science in Finance, Magna Cum Laude · University of Illinois Chicago

Chicago, IL · 2014 - 2018

• GPA: 3.8/4.0
• Relevant coursework included: Financial Modeling, Statistical Analysis, Healthcare Economics