Claims Examiner I at Florida Blue

San Antonio, Texas, United States -

Full Time

Start Date

Immediate

Expiry Date

05 Jun, 26

Salary

0.0

Posted On

07 Mar, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Processing, Adjudication, Claims Research, Medical Necessity Review, Production Standards, Claims Investigation, Settlement Negotiation, Department of Insurance Complaint Response, Overpayment Recovery, Claims Appeals Resolution, Benefit Research, CPT Coding, ICD-9 Coding, COBRA Knowledge, HIPAA Knowledge, Decision-Making

Industry

Insurance

Description

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: * This is a Full time in office position: 19100 Ridgewood Pkwy San Antonio, TX 78259 * Anticipated Training Class Start Dates: 3/30/2026 and 4/27/2026 * Schedule Monday to Friday 8:00am - 4:30pm CST for 4 weeks 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: The essential functions listed represent the major duties of this role, additional duties may be assigned. * 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-9 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 What We Can Offer YOU! To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to: * Medical, dental, vision, life and global travel health insurance * Income protection benefits: life insurance, Short- and long-term disability programs * Flexible schedules after training + future WAH options! * Leave programs to support personal circumstances. * Retirement Savings Plan includes employer contribution and employer match * Paid time off, volunteer time off, and 11 holidays * Additional voluntary benefits available and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ. 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.

Responsibilities

The Claims Examiner will be responsible for the day-to-day processing and adjudication of various healthcare claims, including medical, dental, vision, and mental health claims, verifying coverage under policy guidelines. Key duties also involve facilitating claims investigations, managing overpayment reviews and recovery, and resolving claims appeals.