PARIS SMITH
Greensboro,NC
Summary
Healthcare claims professional skilled in processing and reviewing Medicaid, Medicare, and commercial claims within high-volume environments. Adept at handling complex, non-auto-adjudicated claims, performing detailed manual reviews, and applying coverage, coding, and policy guidelines with accuracy. Proficient in interpreting ICD-10, CPT, and HCPCS coding, resolving claim discrepancies, and managing rework, adjustments, appeals, and denials in compliance with CMS regulations and HIPAA standards. Experienced navigating multiple claims platforms, CRM tools, and payer portals while maintaining precise documentation and consistently meeting productivity and quality metrics. Recognized for analytical thinking, attention to detail, and strong cross-functional collaboration with providers, billing departments, and internal teams.
Overview
8
8
years of professional experience
Work History
Medical Claims Processor
HealthDyne
12.2025 - Current
- Handle high-volume inbound and outbound calls (60–100+ daily) to assist members, patients, and providers with benefit inquiries, eligibility, and claim status, enhancing service delivery and member satisfaction.
- Verify insurance coverage, demographics, and authorization requirements to ensure accurate processing and service delivery.
- Explain plan benefits, EOBs, and claim determinations in a clear, compliant, and professional manner.
- Research and resolve claim issues, including denials, delays, and billing discrepancies, to facilitate accurate claim processing.
- Document all interactions, updates, and resolutions in accordance with HIPAA and company compliance standards.
- Navigate multiple systems, including claims platforms, CRM tools, and payer portals, to access and update account information efficiently.
- Escalate complex issues to appropriate departments while maintaining ownership through resolution.
- Meet or exceed performance metrics including quality scores, average handle time (AHT), first call resolution, and productivity targets.
- Coordinate with providers, billing departments, and internal teams to streamline claim resolution and maintain accurate patient records.
Medical Claims Examiner
One Source Documents Resources
10.2021 - 10.2024
- Reviewed and processed medical claims for accuracy and completeness according to established guidelines.
- Assessed coding accuracy using ICD-10 codes, CPT codes, HCPCS codes, and modifiers.
- Communicated with claimants, medical professionals, and internal teams to gather necessary information and resolve discrepancies.
- Validated that all necessary documentation was included with each claim submission.
- Identified and escalated complex claims issues, contributing to process improvements and reducing errors.
- Maintained organized, accurate electronic claim files and generated periodic reporting on trends and performance.
- Input data into claims systems, maintaining accuracy of provider coding information and reported services.
Claims Specialist
Firstsource
01.2019 - 09.2021
- Processed medical claims for Medicaid and Medicare plans, ensuring accuracy, completeness, and compliance with payer guidelines.
- Reviewed claims for correct coding (ICD-10, CPT, HCPCS), eligibility, and authorization requirements prior to adjudication.
- Analyzed claims that did not auto-adjudicate and performed manual review and resolution based on policy and coverage guidelines.
- Verified member eligibility, benefits, and coverage limits to determine claim payment or denial outcomes.
- Interpreted Explanation of Benefits (EOBs) and claim details to ensure accurate processing and reimbursement.
- Researched and resolved claim discrepancies, denials, and rework requests in accordance with CMS and company policies.
- Processed adjustments, corrections, and resubmitted claims to ensure accurate payment outcomes.
Education
High School Diploma -
Ben L. Smith High School
Greensboro, NCSkills
- High-Dollar & Complex Claims Handling
- Medicaid
- Medicare
- Commercial Plans
- Claims Investigation
- Rework
- Non-Auto-Adjudicated Review
- Appeals Resolution
- Denial Management
- Coverage Determination
- Policy Interpretation
- Benefits Verification
- Eligibility Verification
- ICD-10
- CPT
- HCPCS Coding
- Explanation of Benefits (EOB) Interpretation
- Regulatory Compliance
- HIPAA Compliance
- CMS Guidelines
- Claims Platforms
- CRM
- Payer Portals
- Quality Metrics
- AHT
- Productivity Standards
Timeline
Medical Claims Processor
HealthDyne
12.2025 - Current
Medical Claims Examiner
One Source Documents Resources
10.2021 - 10.2024
Claims Specialist
Firstsource
01.2019 - 09.2021
High School Diploma -
Ben L. Smith High School