Claims Examiner I

WebTPA; Irving (TX); On-site; USD 52,000 - 78,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability benefits

Paid time off

Holidays

Job summary

WebTPA, a GuideWell Company, seeks a Claims Examiner to process and adjudicate medical, dental, vision, and mental health claims for multiple accounts in Irving, TX. You will perform claims research, verify coverage, and ensure policy guideline compliance.

We value 2+ years in medical claims, CPT/ICD-10 coding knowledge, HIPAA and COBRA familiarity, and strong attention to detail with solid communication skills. Comprehensive benefits and retirement plan offered.

Qualifications

• 2+ years of related work experience in medical claims processing and adjudication.
• Experience with CPT/ICD-10 coding, COBRA, HIPAA required.
• Strong attention to detail and ability to verify medical necessity and coverage.

Responsibilities

• Process day-to-day medical, dental, vision, and mental health claims for assigned accounts.
• Perform claims adjudication and research as needed; verify policy coverage and requirements.
• Investigate overpayments, negotiate settlements, and track resolutions.
• Resolve claims appeals and verify benefits; maintain accurate documentation.

Skills

Medical claims processing

Claims adjudication

HIPAA knowledge

CPT ICD-10 coding

Coordination of benefits

Communication skills

High school diploma

Computerized claims system

Education

High school diploma or GED

Tools

Computerized claims system

Job description

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
  • 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
  • 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.

Qualifications:

• 2+ years related work experience.
• Medical claims and adjudication experience on a computerized claims payment system in the healthcare industry.
• High school diploma or GED
• Knowledge of medical coding, CPT, ICD10, COBRA, HIPAA, pre-existing conditions, and coordination of benefits.
• Experience with multiple surgical procedures and establishment of reasonable and customary fees.
• Medical billing and coding courses are a plus.
• Experience in processing all types of medical claims helpful.

What We Can Offer YOU!

To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to:

• 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

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ.

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.

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.