Claims Examiner I

Claims SpecialistClaims SpecialistFull TimeRemoteMid LevelTeam 1,001-5,000H1B SponsorCompany SiteLinkedIn

Location

Texas

Posted

5 days ago

Salary

0

Seniority

Mid Level

High School2 yrs expEnglish

Job Description

Claims Examiner I

GuideWell Source

• 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.

Job 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-10 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

  • Full Time position

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