Jennifer Swank

• Processed and adjudicated cancer, hospital care, accident, critical illness, heart and stroke insurance claims in accordance with policy provisions and benefit guidelines.
• Reviewed medical records, clinical documentation, diagnosis information, and treatment details to determine eligibility and applicable benefits under individual policies.
• Utilized LifePro to process and adjudicate claims and Salesforce to manage cases, documentation, follow-ups, and claim-related activities.
• Applied ICD-10 codes, CPT/procedure codes, and other medical coding information to assist with benefit determination and automated claim adjudication.
• Utilized an automated adjudication system to evaluate claims based on medical and procedural codes, policy requirements, and established benefit criteria.
• Reviewed, processed, and approved or denied claims based on policy language, supporting medical documentation, and applicable claim guidelines.
• Prepared and reviewed claim determination and denial correspondence, ensuring letters accurately communicated the reason for the decision and applicable policy provisions.
• Created and maintained standardized letter templates for claim denials, medical record requests, and other claim-related correspondence.
• Trained new employees on claim processing procedures, system workflows, policy interpretation, medical documentation review, and adjudication processes.
• Developed job aids, process guides, and training materials to support consistency, accuracy, and efficiency in claims processing.
• Collaborated with team members and internal departments to resolve complex claims, obtain missing documentation, and ensure timely claim resolution.

Processed and adjudicated high-volume GapCare claims, averaging 100+ claims per day, while determining applicable benefits based on insurance policy provisions, deductibles, and inpatient versus outpatient services. Reviewed CMS-1500 and UB-04 claim forms, including claims containing multiple diagnosis and procedure codes, to accurately determine eligibility and provider payment amounts. Applied medical coding knowledge and policy guidelines to evaluate services and calculate benefits. Developed extensive familiarity with ICD-10 diagnosis codes, procedure codes, revenue codes, and other medical claim information through daily processing of high-volume healthcare claims. Ensured claims were accurately processed and paid according to policy requirements.