Claims Examiner I
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Job Description
Claims Examiner handling healthcare claims processing, research, and adjudication at WebTPA. Ensuring accuracy in medical claims and verifying coverage under policy guidelines.
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).
- 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.
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.
- 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.
- 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.
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
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