Claims Examiner I

WebTPA•San Antonio, TX

8d•Onsite

About The Position

As a Claims Examiner, you will process and adjudicate healthcare claims, conduct research as appropriate, and handle claims of varying complexity. This is a full-time, in-office position at 19100 Ridgewood Pkwy, San Antonio, TX 78259. The anticipated training class start date is 12/7/2026. The training schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m. Central Time, for four weeks. The role includes day-to-day processing of medical, dental, vision, and mental health claims; reviewing claims for medical necessity and coverage under policy guidelines; and meeting or exceeding qualitative and quantitative production standards. Additional duties include investigating claims, negotiating settlements, interpreting medical records, responding to Department of Insurance complaints, authorizing payments, reviewing and recovering overpayments, maintaining accurate financial histories, and tracking complaints and resolutions. The examiner also resolves appeals, researches benefits, and verifies correct plan loading.

Requirements

At least 2 years of related work experience.
Claims examiner or adjudication experience using a computerized claims payment system in the healthcare industry.
High school diploma or GED.
Knowledge of CPT and ICD-9 coding.
Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits.
Proven judgment, decision-making skills, and analytical ability.
Ability to learn quickly and multitask.
Ability to maintain good rapport with physicians, healthcare facilities, clients, and providers.
Concise written and verbal communication skills, including the ability to handle conflict.
Proficiency with Microsoft Windows, Word, Excel, and customized programs for medical CPT coding.

Nice To Haves

Some college courses in related fields.
Experience processing all types of medical claims.
Data entry and 10-key skills by touch or sight.

Responsibilities

Process medical, dental, vision, and mental health claims for assigned accounts.
Adjudicate claims and conduct claims research where applicable.
Review insurance claims to verify medical necessity and coverage under policy guidelines and clinical edit logic.
Meet and/or exceed qualitative and quantitative production standards.
Facilitate claims investigations, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payments to claimants and providers.
Review and recover claims overpayments and correct financial histories for patients and service providers.
Use systems to track complaints and resolutions.
Resolve claims appeals, research benefits, and verify correct plan loading.
Review multiple surgical procedures and establish reasonable and customary fees.