Claims Examiner I — Remote Options & Benefits

GuideWell; Oregon; Hybrid; USD 52.000 - 70.000; Vollzeit

Benefits dieser Stelle

Medical, dental, vision, life and stay

Income protection: life and disability

Flexible schedules after training

Work-from-home options

Paid time off and holidays

Retirement Savings Plan with employer

Zusammenfassung

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, including research, and work to verify medical necessity and coverage under policy guidelines. You will contribute to meeting production standards while supporting investigation and overpayment recovery as needed.

Qualifikationen

• 2+ years related work experience.
• Experience with claims adjudication 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.
• 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.

Aufgaben

• 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.
• 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.

Kenntnisse

Attention to detail

Analytical reasoning

Multitasking

Written and verbal communication

CPT coding knowledge

HIPAA knowledge

Microsoft Office

Team collaboration

Ausbildung

High school diploma or GED

Some college courses

Tools

CPT coding software

Claims processing system

EMR/PHI systems

Jobbeschreibung

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, including research, and work to verify medical necessity and coverage under policy guidelines. You will contribute to meeting production standards while supporting investigation and overpayment recovery as needed.