Florida Blue · 1 day ago
Claims Examiner I - Part TIme
Irving, TX, United States
Full-time, Part-time
Onsite
Entry, Mid Level
2+ years expWebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30 years of experience in managing customized health plans. They are seeking a Claims Examiner to handle the processing and adjudication of healthcare claims, including claims research and ensuring compliance with policy guidelines.
ConsultingHealth CareInsurance
Responsibilities
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
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
Qualification
Required
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
Preferred
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
Company
Florida Blue
Florida Blue is a subsidiary of a not-for-profit health solutions company dedicated to serving all Floridians in the pursuit of health.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Patrick Geraghty
President and CEO
Recent News
2025-11-04
Company data provided by crunchbase