Claims Examiner I

WebTPA•Irving, TX

15h

About The Position

WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30 years of experience building benefit solutions and managing customized health plans. The Claims Examiner I processes and adjudicates healthcare claims of varying complexity, including conducting claims research where applicable. The role handles medical, dental, vision, and mental health claims, and reviews insurance for medical necessity and coverage under policy guidelines and clinical edit logic. Employees are expected to meet or exceed qualitative and quantitative production standards. The position also supports claims investigations and overpayment administration, including negotiating settlements, interpreting medical records, responding to Department of Insurance complaints, authorizing payments to claimants and providers, and reviewing and recovering overpayments. The examiner uses systems to track complaints and resolutions, resolves claims appeals, researches benefits, and verifies correct plan loading. Anticipated training class start dates are December 7, 2026, and January 19, 2027. The training schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m. Central Time, for four weeks. Flexible schedules and work-at-home options may be available after training.

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 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.
Ability to review multiple surgical procedures and establish reasonable and customary fees.

Nice To Haves

Some college coursework in related fields.
Experience processing all types of medical claims.
Data-entry skills and 10-key proficiency 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 to verify medical necessity and coverage under policy guidelines and 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 and recover claims overpayments, and correct patient and service-provider financial histories to ensure accurate records.
Use systems to track complaints and resolutions.
Resolve claims appeals, research benefits, and verify correct plan loading.