索赔审查员 I - 兼职
Claims Examiner I - Part TIme
我们是谁！
WebTPA，一家GuideWell公司，是一家拥有30多年经验的医疗第三方管理机构，专注于构建独特的福利解决方案并管理定制化的健康计划。
关键职位详情：
- 培训时间：周一至周五 中部时间 上午8:00至下午4:30
- 培训时长：4周
- 全职岗位
你的影响是什么？
作为理赔审查员，你将处理和裁定医疗理赔。这包括在适用情况下进行理赔研究以及各种复杂程度的理赔。
你将负责：
- 日常理赔处理：
- 负责理赔处理（医疗、牙科、视力和心理健康理赔）
- 理赔处理和裁定。
- 在适用情况下进行理赔研究。
- 审核并处理保险以验证医疗必要性和保单条款下的覆盖范围（临床编辑逻辑）。
- 岗位人员需达到或超过定性和定量的生产标准。
- 调查和超额支付管理：
- 协助理赔调查，协商和解，解读医疗记录，回应保险部门投诉，并授权向理赔人和提供者付款。
- 进行超额支付审查并追回超额支付的理赔；纠正患者和服务提供者的财务历史，以确保准确记录。
- 使用系统跟踪投诉和解决情况。
- 其他职责包括处理理赔上诉、研究福利、验证正确的计划加载。
你需要具备：
- 2年以上相关工作经验。
- 在医疗行业使用计算机化理赔支付系统进行理赔审查/裁定的经验。
- 高中文凭或同等学历
- 需要掌握CPT和ICD-10编码知识。
- 需要了解COBRA、HIPAA、既往症和利益协调。
- 需要具备良好的判断力、决策能力和分析能力。
- 能够快速学习并同时处理多项任务。
- 精通与医生、医疗机构、客户和提供者建立良好关系。
- 需要具备简洁的书面和口头沟通能力，包括处理冲突的能力。
- 熟练使用Microsoft Windows和Word、Excel以及用于医疗CPT编码的定制程序。
- 审核多种手术程序并确定合理且常见的费用。
我们更青睐：
- 相关领域的部分大学课程
查看英文原文
Get To Know Us!
WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans.
Key position details:
- Training Schedule: Monday to Friday 8:00am to 4:30pm Central Time
- Training Duration: 4 weeks
- Full Time position
What is your impact?
As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity.
What Will You Be Doing:
- 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.
What You Must Have:
- 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.
What We Prefer:
- 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
General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.
Originally posted on Himalayas