Claims Examiner I

GuideWell

81d

About The Position

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. As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity.

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-9 coding required.
• Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required.
• 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.

Nice To Haves

• 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.

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).
• Meet and/or exceed qualitative and quantitative production standards.
• 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.
• Resolve claims appeals, research benefits, verify correct plan loading.

Benefits

• Medical, dental, vision, life and global travel health insurance.
• Income protection benefits: life insurance, Short- and long-term disability programs.
• Leave programs to support personal circumstances.
• Retirement 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED