Medical Claims Examiner
Job Description:
- Review, analyze, and process complex self-funded medical claims from start to finish.
- Utilize the WLT system daily to adjudicate claims, ensuring all coding, billing, and pricing rules are applied correctly.
- Verify patient eligibility, benefit limits, and plan coverage exclusions based on specific self-funded plan documents.
- Identify and investigate claims requiring additional information, such as coordination of benefits (COB), subrogation, or medical necessity reviews.
- Maintain strict compliance with all federal and state regulations, including HIPAA and ERISA guidelines.
- Meet or exceed established quality accuracy and production turnaround standards.
Requirements:
- WLT System Experience: Proven, hands-on experience adjudicating claims within the WLT software platform. (Candidates without WLT experience will not be considered).
- Self-Funded Expertise: Demonstrated background processing self-funded medical health insurance claims.
- Contractor Readiness: Ability to work independently as a 1099 contractor, managing your own remote office setup and schedule to meet production targets.
- Technical Setup: A secure, HIPAA-compliant home office environment with high-speed internet.
- TPA Experience: Previous experience working within a Third Party Administrator (TPA) environment is highly preferred and will make you a standout candidate.
- Deep understanding of medical terminology, CPT, ICD-10, HCPCS codes, and standard billing forms (UB-04, CMS-1500).
Benefits:
