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Claims resolution specialist skills for your resume and career

Updated January 8, 2025
6 min read
Quoted expert
Rachel Domnick
Below we've compiled a list of the most critical claims resolution specialist skills. We ranked the top skills for claims resolution specialists based on the percentage of resumes they appeared on. For example, 12.9% of claims resolution specialist resumes contained patients as a skill. Continue reading to find out what skills a claims resolution specialist needs to be successful in the workplace.

15 claims resolution specialist skills for your resume and career

1. Patients

Here's how claims resolution specialists use patients:
  • Coordinated payment arrangements for personal injury and cash patients on delinquent accounts.
  • Documented all communication from both patients and insurance representatives.

2. Medical Terminology

Here's how claims resolution specialists use medical terminology:
  • Gained knowledge of (CPT) procedure and (ICD-9) diagnostic codes, billing practices and mental health medical terminology.
  • Enter claims data into system while interpreting coding with comprehensive understanding of medical terminology in relation to diagnoses and procedures.

3. Insurance Claims

Here's how claims resolution specialists use insurance claims:
  • Reviewed, investigated and performed re-work on insurance claims for assigned territory.
  • Guided automobile insurance claims from initial report to completion.

4. Patient Accounts

Patient accounts are a part of a hospital information system that is used for storing financial data, keeping a record of healthcare costs, and providing information regarding patient billing. It deals with the financial aspects of the healthcare setting.

Here's how claims resolution specialists use patient accounts:
  • Analyze and audit patient accounts to ensure correct patient and insurance balances.
  • Completed processing of patient accounts within the time requirements.

5. Medicaid

Here's how claims resolution specialists use medicaid:
  • Process medical claims submitted to Kansas Medicaid using established guidelines and policies.
  • Uphold Medicare, Medicaid, and HIPAA compliance guidelines in relation to billing, Collections, and PHI information.

6. CPT

CPT is a medical term that stands for Current Procedural Terminology. Whenever a procedure like surgery or diagnosis occurs or some other medical service is rendered to a patient, it is reported to the concerned physician, insurance company, or organization. The aforementioned practice is widely referred to as CPT.

Here's how claims resolution specialists use cpt:
  • Research CPT Code authorizations, authorization status, and claim denial reasons.
  • Researched CPT ,ICD-9, ICD-10 coding discrepancies for compliance and reimbursement accuracy.

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7. Phone Calls

Phone calls are a wireless or wired connection made over a telephone or a mobile phone between two people. Two parties are involved in a phone call, the caller and the receiver. A caller dials the number of the one he wants to call, and the recipient hears a bell or a tune to which he picks up the call. The call establishes a connection between them through which they can communicate. The voice is converted into signals and is transmitted through wired or wireless technology.

Here's how claims resolution specialists use phone calls:
  • Initiate provider telephone calls as often required with respect to proposals and respond to providers following receipt of proposals.
  • Make return phone calls to providers to educate on contracts, reimbursement policies, and other claim issues.

8. Medical Billing

Here's how claims resolution specialists use medical billing:
  • Managed and maintained all aspects of medical billing for inpatient/outpatient mental health facility that employed 10 Professionals.
  • Backed by academic qualifications including upcoming and extensive course work in medical billing and coding procedures.

9. Appeals

Here's how claims resolution specialists use appeals:
  • Investigate Practitioner and Hospital Claim Appeals for Increased Payment and Reimbursement guidelines to determine whether allowed payment was appropriate.
  • Corresponded with physicians and patient account representatives to review explanation of benefits, medical records, and medical appeals.

10. Customer Service

Customer service is the process of offering assistance to all the current and potential customers -- answering questions, fixing problems, and providing excellent service. The main goal of customer service is to build a strong relationship with the customers so that they keep coming back for more business.

Here's how claims resolution specialists use customer service:
  • Provided policyholders with exceptional customer service, consistently meeting or exceeding in all categories of the yearly performance reviews.
  • Handled escalated customer complaints, provided superior customer service and determined a fair claim resolution.

11. Outbound Calls

An outbound call is made by the call center representative to the customers on behalf of the company. Such calls help increase sales and generate revenue for the organization.

Here's how claims resolution specialists use outbound calls:
  • Place outbound calls to providers of service in an attempt to negotiate settlement agreements on the out of network medical claims.
  • Call Center Environment* Inbound Calls* Reviewed Customer Policies* Placed Claims* Outbound Calls to follow up on ongoing claims.

12. Medical Claims

Here's how claims resolution specialists use medical claims:
  • Negotiated non-contracted medical claims for major insurance carriers.
  • Represent and demonstrate a thorough knowledge of medical claims and all Affinity Health Plan product lines of business.

13. EOB

EOB stands for explanation of benefits. This is a common outline provided as part of many health insurance plans to explain what services were completed, the co-pay required for each appointment, and how much of your payment is covered by health insurance. EOB is an indication that your insurance claim has already been processed.

Here's how claims resolution specialists use eob:
  • Posted payments according to the EOB, made adjustment for Provider discounts, and billed patient responsibilities to deductibles and co-insurances.
  • Processed an average of 500 weekly medical insurance claim incoming entering the EOB's, claims, reprise claims.

14. HIPAA

Here's how claims resolution specialists use hipaa:
  • Demonstrated effective verbal communication skills by interacting with providers while being compliant with HIPAA standards
  • Handled confidential information and ensured all HIPAA and State requirements and regulations were adhered to at all times.

15. Claims Issues

Here's how claims resolution specialists use claims issues:
  • Act as a Liaison with providers, internal departments, clients, claims and the claims processing department with claims issues.
  • Position Summary: Manage insurance accounts to address claims issues and thereby affect payment and /or bringing them to resolution.
top-skills

What skills help Claims Resolution Specialists find jobs?

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What hard/technical skills are most important for claims resolution specialists?

Rachel Domnick

Instructor of Professional Practice, MS Program Coordinator, Oklahoma State University

In designing this effort, our master's faculty selected five key competencies from the Korn Ferry Leadership Architect framework to augment the technical skills that are the focus of our program. Those competencies include ensuring accountability, managing ambiguity, collaborating, communicating effectively, and self-awareness. As part of the first course in our master's program, students are introduced to these competencies and guided to understand how they tie into the accounting profession. Students are provided with resources to understand the competencies, and instructors explicitly label activities and assignments with the competencies to which it ties.

Further, at multiple points during their master's experience, each student receives an individualized report containing feedback from master's faculty and their fellow master's students. Students also have the opportunity to understand better the feedback they've received through tailored sessions with a career center staff person trained in the Korn Ferry framework.
Do you want to know more?
Read more about what experts have to say about claims resolution specialist

List of claims resolution specialist skills to add to your resume

Claims resolution specialist skills

The most important skills for a claims resolution specialist resume and required skills for a claims resolution specialist to have include:

  • Patients
  • Medical Terminology
  • Insurance Claims
  • Patient Accounts
  • Medicaid
  • CPT
  • Phone Calls
  • Medical Billing
  • Appeals
  • Customer Service
  • Outbound Calls
  • Medical Claims
  • EOB
  • HIPAA
  • Claims Issues
  • Insurance Carriers
  • Data Entry
  • Policy Coverage
  • ICD-9
  • Process Claims
  • SIU
  • Client Guidelines
  • Payment Issues
  • Quality Service
  • Status Updates
  • Insurance Verification
  • Hippa
  • Inbound Calls
  • Identify Trends
  • Quality Standards
  • Simple Adjustments
  • Provider Issues
  • CMS
  • Claims Handling
  • Customer Inquiries
  • Emergency Repairs
  • Processing Systems
  • Billing Issues
  • Insurance Coverage
  • Health Plan
  • Medical Documentation
  • Patient Eligibility
  • System Knowledge
  • EDI
  • Floor Support
  • Party Claims
  • Arbitration
  • Provider Contracts

Updated January 8, 2025

Zippia Research Team
Zippia Team

Editorial Staff

The Zippia Research Team has spent countless hours reviewing resumes, job postings, and government data to determine what goes into getting a job in each phase of life. Professional writers and data scientists comprise the Zippia Research Team.

Updated January 8, 2025

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