Claims Examiner I

GuideWell•San Antonio, TX

2d•Onsite

About The Position

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 Central Time 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.

Requirements

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.

Nice To Haves

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

Responsibilities

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.

Benefits

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
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.