Medical Claims Examiner
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About The Position
Get To Know Us! 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 Medical Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity. This is a fully in-office position located at 8500 Freeport Parkway, Irving, Texas 75063. The training schedule is from 8:00 am to 4:30 pm, Monday to Friday. The essential functions listed represent the major duties of this role, additional duties may be assigned. The day-to-day processing of claims accounts for 80% of the role, where you will be responsible for processing medical, dental, vision, and mental health claims. This includes claims processing and adjudication, as well as claims research where applicable. You will review and process insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic). Incumbents are expected to meet and/or exceed qualitative and quantitative production standards. Investigation and overpayment administration account for 10% of the role. You will facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers. This includes overpayment reviews and recovery of claims overpayment, as well as correcting financial histories of patients and service providers to ensure accurate records. You will utilize systems to track complaints and resolutions. Other responsibilities include resolving claims appeals, researching benefits, and verifying correct plan loading.
