Claims Examiner I

About the role

WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans.

Responsibilities

• Day-to-day processing of claims for accounts
• Responsible for processing of claims (medical, dental, vision, and mental health claims)
• Claims processing and adjudication
• Claims research where applicable. Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic).
• Investigation and overpayment administration: Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers.
• Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records.
• Utilize systems to track complaints and resolutions.
• Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading.

Requirements

• 2+ years related work experience.
• Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry.
• High school diploma or GED.
• Knowledge of CPT and ICD-10 coding required.
• Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required.
• Must possess proven judgment, decision-making skills and the ability to analyze.
• Ability to learn quickly and multitask.
• Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers.
• Concise written and verbal communication skills required, including the ability to handle conflict.
• Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding.
• Review of multiple surgical procedures and establishment of reasonable and customary fees.

Qualifications

• Some college courses in related fields are a plus.
• Other experience in processing all types of medical claims helpful.
• Data entry and 10-key by touch/sight.

Skills

• Knowledge of CPT and ICD-10 coding.
• Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits.
• Proven judgment, decision-making skills and the ability to analyze.
• Ability to learn quickly and multitask.
• Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers.
• Concise written and verbal communication skills required, including the ability to handle conflict.
• Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding.
• Review of multiple surgical procedures and establishment of reasonable and customary fees.

Benefits

• To support your wellbeing, comprehensive benefits are offered.
• Medical, dental, vision, life and global travel health insurance.
• Income protection benefits: life insurance, Short- and long-term disability programs.
• Flexible schedules after training + WAH options!
• Leave programs to support personal circumstances.
• Retail Savings Plan includes employer contribution and employer match.
• Paid time off, volunteer time off, and 11 holidays.
• Additional voluntary benefits available and a comprehensive wellness program.

Pay

Pay details are not specified in this posting.

Schedule

Monday to Friday 8:00am - 4:30pm Central Time for 4 weeks.