Claims Examiner I

WebTPA; Irving (TX); On-site; USD 45,000 - 65,000; Full time

Job summary

WebTPA, a GuideWell Company, seeks a Claim Examiner to handle processing and adjudication of healthcare claims (medical, dental, vision, and mental health). You will research claims, verify coverage, and ensure adherence to policy guidelines while meeting production standards.

You will work from our Irving, TX office in a full-time role with a focus on accuracy, compliance, and effective communication with providers and clients.

Qualifications

• 2+ years related work experience.
• Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry.
• Knowledge of CPT and ICD-10 coding.
• Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits.
• Must possess proven judgment, decision-making skills and the ability to analyze.
• Ability to learn quickly and multitask.
• Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers.
• Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding.
• Review of multiple surgical procedures and establishment of reasonable and customary fees.

Responsibilities

• Day-to-day processing of claims for accounts (medical, dental, vision, and mental health).
• Claims processing and adjudication.
• Claims research where applicable.
• Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic).
• Incumbents are expected to meet and/or exceed qualitative and quantitative production standards.
• Investigation and overpayment administration: facilitate claims investigation, negotiate settlements, interpret medical records, respond to DOl complaints, and authorize payment to claimants and providers.
• Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records.
• Utilize systems to track complaints and resolutions.
• Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading.

Skills

Claims processing

Adjudication

CPT/ICD-10 knowledge

Microsoft Office

Analytical skills

Communication skills

Time management

Education

High school diploma or GED

Some college courses

Tools

Microsoft Windows

MS Word

MS Excel

Custom CPT coding software

Job description

Get To Know Us!

WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans.

Key position details:

• Training Schedule: Monday to Friday 8:00am to 4:30pm Central Time
• Training Duration: 4 weeks
• Anticipated training class start dates: 9/14/2026 or 10/12/2026
• Full Time position

What is your impact?

As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity.

What Will You Be Doing:

• Day-to-day processing of claims for accounts:
  • Responsible for processing of claims (medical, dental, vision, and mental health claims)
  • Claims processing and adjudication.
  • Claims research where applicable.
  • Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic).
  • Incumbents are expected to meet and/or exceed qualitative and quantitative production standards.
• Investigation and overpayment administration:
  • Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers.
  • Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records.
  • Utilize systems to track complaints and resolutions.
• Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading.

What You Must Have:

• 2+ years related work experience.
• Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry.
• High school diploma or GED
• Knowledge of CPT and ICD-10 coding required.
• Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required.
• Must possess proven judgment, decision-making skills and the ability to analyze.
• Ability to learn quickly and multitask.
• Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers.
• Concise written and verbal communication skills required, including the ability to handle conflict.
• Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding.
• Review of multiple surgical procedures and establishment of reasonable and customary fees.

What We Prefer:

• Some college courses in related fields are a plus.
• Other experience in processing all types of medical claims helpful.
• Data entry and 10-key by touch/sight

General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.