This job includes claim processing and adjudication, with claims research where applicable. Incumbents must meet and/or exceed qualitative and quantitative production standards. Claims processing may range in level of complexity.

Location:

Onsite in our San Antonio, Texas office – 19100 Ridgewood Parkway 78259

What We Offer:

• Insurance Benefits
• 401(k) Match
• Wellness Incentives
• Growth Opportunities
• Paid Time Off + Holidays
• Amazing In-Office Culture

Essential Functions

• 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.

Required Experience

• 3+ years related work experience in 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.
  Must learn quickly as well as be able to multi-task.
• Must be motivated and possess a sound work ethic.
• 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.

Preferred Qualifications

• Some college courses in related field a plus.
• Other experience in processing all types of medical claims helpful.
• Data entry and 10-key by touch/sight required.

General Physical Demands

• 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 Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive, and equitable culture for our employees and communities.