Claims Examiner

$51,000 - $82,000/Yr

Webtpa Employer Services - San Antonio, TX

Full-time

Onsite - San Antonio, TX

Insurance Carriers and Related Activities

About the position

The Claims Examiner position at WebTPA Employer Services, LLC involves a critical role in the processing and adjudication of various claims, including medical, dental, vision, and mental health claims. The incumbent will be responsible for ensuring that claims are processed accurately and efficiently, adhering to both qualitative and quantitative production standards. This role requires a thorough understanding of insurance policies and the ability to verify medical necessities and coverage under policy guidelines, utilizing clinical edit logic. In addition to claims processing, the position entails conducting claims research when necessary, facilitating investigations into claims, negotiating settlements, and interpreting medical records. The Claims Examiner will also handle overpayment administration, which includes reviewing claims for overpayments, correcting financial histories, and ensuring accurate records for both patients and service providers. The role demands proficiency in tracking complaints and resolutions, as well as resolving claims appeals and verifying correct plan loading. The position is based in the San Antonio office, and while it does not specify a work-at-home option, it emphasizes the importance of meeting production standards and maintaining effective communication with healthcare providers and clients. The Claims Examiner will be expected to manage a variety of tasks simultaneously, demonstrating strong judgment and decision-making skills throughout the claims process.

Responsibilities

• Day-to-day processing of claims for accounts, including medical, dental, vision, and mental health claims.
• Claims processing and adjudication, ensuring adherence to policy guidelines.
• Conducting claims research where applicable to verify medical necessities and coverage.
• Facilitating claims investigations, negotiating settlements, and interpreting medical records.
• Responding to Department of Insurance complaints and authorizing payments to claimants and providers.
• Managing overpayment reviews and recovery of claims overpayment, ensuring accurate financial histories.
• Utilizing systems to track complaints and resolutions related to claims.
• Resolving claims appeals and researching benefits to verify correct plan loading.

Requirements

• 3+ years of related work experience in claims examination or adjudication within the healthcare industry.
• High school diploma or GED is required.
• Knowledge of CPT and ICD-9 coding is essential.
• Understanding of COBRA, HIPAA, pre-existing conditions, and coordination of benefits is required.
• Proven judgment and decision-making skills, with the ability to analyze complex information.
• Ability to learn quickly and manage multiple tasks effectively.
• Strong work ethic and motivation to meet production standards.
• Excellent written and verbal communication skills, including conflict resolution capabilities.
• Proficiency in Microsoft Windows, Word, Excel, and customized programs for medical CPT coding.

Nice-to-haves

• Some college courses in a related field are a plus.
• Additional experience in processing various types of medical claims is helpful.
• Data entry skills and proficiency in 10-key by touch/sight are required.