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Insurance Claims Reviewer

2 months ago

Irving, Texas, United States GuideWell Full time
Job Overview

About Us

GuideWell is a prominent healthcare third-party administrator with over three decades of expertise in developing tailored benefit solutions and managing personalized health plans.

Position Highlights:
  • This role requires full-time office presence.
  • Standard training hours are Monday to Friday, 8:00 AM to 4:30 PM.
Your Role:
As a Claims Examiner, you will be responsible for the processing and adjudication of healthcare claims. This includes conducting claims research as necessary and managing a variety of claim complexities.

Key Responsibilities:

The following duties represent the primary responsibilities of this position, with additional tasks assigned as needed:
  • Claims Processing (80%):
    • Manage the processing of various claims, including medical, dental, vision, and mental health.
    • Oversee claims adjudication and processing.
    • Conduct claims research when required.
    • Evaluate and process insurance claims to confirm medical necessity and coverage in accordance with policy guidelines.
    • Meet or exceed established qualitative and quantitative performance standards.
  • Investigation and Overpayment Management (10%):
    • Facilitate investigations into claims, negotiate settlements, interpret medical documentation, and address complaints from regulatory bodies.
    • Review overpayments and recover claims overpayments, ensuring accurate financial records for patients and service providers.
    • Utilize tracking systems for complaints and resolutions.
  • Additional Duties (10%):Handle claims appeals, research benefits, and verify correct plan loading.
Qualifications:
  • Minimum of 3 years of relevant experience.
  • Experience in claims examination and adjudication using computerized claims payment systems within the healthcare sector.
  • High school diploma or GED required.
  • Familiarity with CPT and ICD-9 coding is essential.
  • Understanding of COBRA, HIPAA, pre-existing conditions, and coordination of benefits is necessary.
  • Demonstrated judgment and decision-making abilities, along with analytical skills.
  • Ability to learn swiftly and manage multiple tasks effectively.
  • Strong interpersonal skills to maintain positive relationships with healthcare providers and clients.
  • Excellent written and verbal communication skills, including conflict resolution capabilities.
  • Proficiency in Microsoft Windows, Word, Excel, and specialized medical coding software.
  • Experience in reviewing surgical procedures and determining reasonable and customary fees.
Preferred Qualifications:
  • Some college coursework in related fields is advantageous.
  • Experience in processing various types of medical claims is beneficial.
  • Data entry skills and proficiency in 10-key by touch/sight.
What We Offer:

We provide a comprehensive benefits package to support your well-being, including:
  • Medical, dental, vision, life, and global travel health insurance.
  • Income protection benefits such as life insurance and short- and long-term disability programs.
  • Leave programs to accommodate personal circumstances.
  • Retirement savings plan with employer contributions and matching.
  • Paid time off, volunteer time off, and designated holidays.
  • Additional voluntary benefits and a comprehensive wellness program.
Employee benefits are designed to comply with federal and state employment laws and may vary based on the location of employment.

Physical Demands:

This position involves sedentary work, requiring the exertion of up to 10 pounds of force occasionally to move objects. Jobs are considered sedentary if walking or similar activities are required only occasionally.

We are an Equal Opportunity/Protected Veteran/Disabled Employer dedicated to fostering a diverse, inclusive, and equitable culture for our employees and communities.

About Our Commitment:

At GuideWell, we prioritize diversity, equity, and inclusion in all aspects of our operations. We believe in hiring individuals who reflect the communities we serve and in creating a workplace that fosters a sense of belonging for everyone, regardless of their background.