Claims Examiner I

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.

Work arrangement
Yes