Claims Examiner I

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.

What is your impact?
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.

What Will You Be Doing:

• Day-to-day processing of claims for accounts (80%):
  
  
  
  • 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).
  • Incumbents are expected to meet and/or exceed qualitative and quantitative production standards.
  
  
• Investigation and overpayment administration (10%):
  
  
  
  • 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. (10%)

What You Must Have:

• 2+ years related medical claims examiner/adjudication experience 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.
• Must possess proven judgment, decision-making skills and the ability to analyze.

General Physical Demands: Sedentary work. Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.