Claims Examiner I

GuideWell•Irving, TX

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, conducts claims research when applicable, and helps ensure claims are handled according to policy guidelines. The position may process medical, dental, vision, and mental health claims. The role also supports claim investigations and overpayment administration, including reviewing medical records, negotiating settlements, responding to Department of Insurance complaints, authorizing payments, and maintaining accurate financial histories. Additional duties include resolving appeals, researching benefits, and verifying plan loading. Employees are expected to meet or exceed qualitative and quantitative production standards. Training is scheduled for four weeks, Monday through Friday, 8:00 a.m. to 4:30 p.m. Central Time. Anticipated training class start dates are December 7, 2026, and January 19, 2027. Flexible schedules after training and work-at-home options are available.

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 medical CPT coding programs.

Nice To Haves

Some college courses in related fields.
Experience processing all types of medical claims.
Data-entry skills and 10-key proficiency by touch or sight.

Responsibilities

Process and adjudicate medical, dental, vision, and mental health claims for assigned accounts.
Research claims when applicable and review claims for medical necessity and coverage under policy guidelines and clinical edit logic.
Meet or exceed qualitative and quantitative production standards.
Facilitate claim 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 patient and service-provider financial histories.
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.