Claims Examiner I

GuideWell•San Antonio, TX

7d•Onsite

About The Position

WebTPA, a GuideWell Company, is a healthcare third-party administrator with more than 30 years of experience building benefit solutions and managing customized health plans. The Claims Examiner I processes and adjudicates healthcare claims across a range of complexity, researching claims when applicable. The role is full-time and in-office at 19100 Ridgewood Pkwy, San Antonio, TX 78259. 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. The role processes medical, dental, vision, and mental health claims; applies clinical edit logic to verify medical necessity and coverage under policy guidelines; and is expected to meet or exceed qualitative and quantitative production standards. Duties also include claims investigations, settlement negotiations, medical-record interpretation, responses to Department of Insurance complaints, payment authorization, overpayment review and recovery, appeals resolution, benefit research, and verification of 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 and decision-making skills and 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 skills and ability to use a 10-key by touch or sight.

Responsibilities

Process and adjudicate medical, dental, vision, and mental health claims for assigned accounts.
Research claims as applicable and review coverage and medical necessity using 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 claim 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.