Medical Claims Adjudicator Resume

Updated on: February 25, 2018


Reading the job description on the advertisement that you are replying to, is the best way for you to make a medical claims adjudicator resume that is as near perfect as possible.

If you are applying for several jobs at the same time, create appropriately-named versions of your resume for each one of them. Do not send a generic resume to all prospective employers.

The secret to writing a good resume lies in the job advertisement.

Through them, you can quickly determine what exactly it is that the employer is looking for and you can tweak your resume accordingly. You can even find out things that are not specified by determining the way a particular sentence is written – there are hidden clues in how an employer words an advertisement.

A resume sample for a medical claims adjudicator is provided below:

See also: Claims Adjudicator Resume Sample 1


Medical Claims Adjudicator Resume Sample



Maria Young

53 Buckcreek Drive ● Reno, NV 25896 ● (000) 444-1414 ● maria.young @ email . com


Thorough and well-organized individual who has an inherent capacity to delve deep into matters to bring out credible information. 8+ years’ successful experience in handling medical claims adjudication cases with a high score of success. Talented in determining the eligibility of medical claims by performing in-depth reviews of claim requests, adjudicating medical claims and taking appropriate actions to resolve discrepancies, utilizing up to date processes and procedures to update claims in the database and responding to claimants by staying within company standards to ensure absolute conformity and reduced risk for ambiguity.


• Eligibility Determination • Claims Verification
• Information Analysis • Follow-up
• Regulatory Audits • Alternatives Identification
• Denial Handling • Negotiation
• Process Improvement • Compliance
• Claim Resubmission • Scene Analysis


QUALITY HEALTH PLANS, Reno, NV (5/2013 to Present)
Medical Claims Adjudicator

• Engage clients in conversation to determine the authenticity of their claims.
• Verify claims by coordinating efforts with hospitals and law enforcement agencies.
• Analyze information on applications for any missing or questionable items and ensure that the said discrepancies are handled immediately.
• Key in requests into internal database systems using updated processing procedures.
• Analyze the details of each claim to determine if it should be paid or denied.
• Assist clients in acquiring payment of claims wrongfully or erroneously rejected.
• Contact insurance companies and medical facilities to determine type and duration of clients’ insurance policies.
• Refer to eligibility, authorization, benefit and pricing information to determine the correct course of action.
• Conduct research regarding benefits issues, fraud, and third-party liability.
• Prepare materials for internal auditing activities such as quality control and compliance.

Key Results and Accomplishments
• Successfully acquired payment for 42 denied medical claims(over 3 years) by submitting separate appeals for each.
• Discovered and reported a fraudulent medical claim, saving the company $1m in wrongful payouts.
• Adjudicated a medical claim from a client who had lost both legs in a safari park accident which had been in process for 32 months.
• Improved the efficiency of the adjudication process by introducing and implementing verification and eligibility procedures.

SENIOR WHOLE HEALTH, Reno, NV (1/2007 to 5/2013)
Insurance Claims Clerk

• Review clients’ insurance policies to determine correctness and eligibility.
• Prepare medical insurance claims forms and ensure that they are filled in with accurate information.
• Calculate the number of claims and any current or eligible riders and post them in the internal database.
• Coordinate efforts with claims adjudicators to determine the authenticity of filed claims.
• Contact insured or nominees to obtain missing information to ensure that the claim is complete before it is filed.

High School Diploma