Claims Examiner I

GuideWell•Irving, TX

About The Position

WebTPA, a GuideWell Company, is a healthcare third-party administrator that builds benefit solutions and manages customized health plans. The Claims Examiner I processes and adjudicates healthcare claims of varying complexity, including medical, dental, vision, and mental health claims. The role researches claims as needed and reviews coverage and medical necessity under policy guidelines and clinical edit logic. 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-9 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 proficiency by touch or sight.

Responsibilities

Process medical, dental, vision, and mental health claims for assigned accounts.
Adjudicate claims and conduct claim research as applicable.
Review insurance claims 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 overpayments and recover claim overpayments; correct patient and provider 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.