Medical Claims Examiner
T
TridentHealth Insurance
United StatesContractMiddle
Salary30 USD per hour
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Job Details
Requirements
- Proven, hands-on experience adjudicating claims within the WLT software platform.
- Demonstrated background processing self-funded medical health insurance claims.
- Ability to work independently as a 1099 contractor, managing your own remote office setup and schedule to meet production targets.
- Secure, HIPAA-compliant home office environment with high-speed internet.
- Deep understanding of medical terminology, CPT, ICD-10, HCPCS codes, and standard billing forms (UB-04, CMS-1500) is preferred.
- Previous experience working within a Third Party Administrator (TPA) environment is highly preferred.
Responsibilities
- 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.
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