Claims Examiner I

Job not on LinkedIn

🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

📋 Claims Specialist

🚫👨‍🎓 No degree required

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 13%

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GuideWell Source

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

GuideWell Source is a company within the GuideWell Family that focuses on accelerating innovative health solutions to market, transforming and reshaping the health industry. It specializes in healthcare delivery, providing new models and superior outcomes for patients. The company emphasizes consumerism in healthcare, engaging clients in meaningful ways. GuideWell Source offers healthcare insurance, protecting employers and consumers with coverage plans and services. The company also provides administrative and claims processing services for state and federal Medicare and Medicaid programs, establishing itself as a trusted business partner in the healthcare sector with a focus on operational excellence.

📋 Description

• Process and adjudicate healthcare claims, including medical, dental, vision, and mental health claims • Conduct claims research where applicable across varying claim complexity • Review and process insurance to verify medical necessity and coverage under policy guidelines using clinical edit logic • Meet and/or exceed qualitative and quantitative production standards • Facilitate claims investigations, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payments to claimants and providers • Review and recover claim overpayments • Correct financial histories of patients and service providers to ensure accurate records • Use systems to track complaints and resolutions • Resolve claims appeals • Research benefits • Verify 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 • Proven judgment, decision-making skills, and ability to analyze • Ability to learn quickly and multitask • Ability to maintain good rapport with physicians, healthcare facilities, clients, and providers • Concise written and verbal communication skills, including 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 • Some college courses in related fields are a plus • Other experience in processing all types of medical claims helpful • Data entry and 10-key by touch/sight

🏖️ Benefits

• Medical, dental, vision, life and global travel health insurance • Short- and long-term disability programs • Flexible schedules after training • Leave programs to support personal circumstances • Retirement Savings Plan with employer contribution and employer match • Paid time off • Volunteer time off • 11 holidays • Additional voluntary benefits • Comprehensive wellness program