Claims Examiner I

WebTPA • United States,

8d

About The Position

WebTPA, a GuideWell Company, is a healthcare third-party administrator with more than 30 years of experience developing benefit solutions and managing customized health plans. The Claims Examiner I processes and adjudicates healthcare claims across a range of complexity, conducting research where applicable. The anticipated training class starts December 7, 2026. Training is scheduled Monday through Friday, 8:00 a.m. to 4:30 p.m. Central Time, for four weeks.

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-10 coding.
• Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits.
• Proven judgment and decision-making skills, with the ability to analyze.
• 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 coursework 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 and process insurance to verify medical necessity and coverage under policy guidelines, including clinical edit logic.
• Meet 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 overpayments and recover claim overpayments; correct patients’ and service providers’ financial histories to ensure accurate records.
• 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.

Benefits

• Medical, dental, vision, life, and global travel health insurance.
• Income protection benefits, including life insurance and short- and long-term disability programs.
• Flexible schedules after training and work-at-home options.
• Leave programs to support personal circumstances.
• Retirement Savings Plan with employer contribution and employer match.
• Paid time off, volunteer time off, and 11 holidays.
• Additional voluntary benefits and a comprehensive wellness program.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED