Claims Examiner I

GuideWell; Irving (TX); On-site; USD 52,000 - 72,000; Full time

Job summary

WebTPA, a GuideWell Company, seeks a Claim Examiner in Irving, TX. You will handle day-to-day processing of healthcare claims (medical, dental, vision, and mental health) and adjudication, ensuring accuracy and policy compliance.

This role requires at least 2 years of claims experience, CPT/ICD-10 knowledge, HIPAA awareness, and strong written and verbal communication. You will work in a collaborative environment with physicians, facilities, and providers.

Qualifications

• 2+ years related work experience in claims processing.
• Experience with a computerized claims payment system in healthcare.
• High school diploma or GED.
• Knowledge of CPT and ICD-10 coding.
• Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits.
• Strong judgment, decision-making and analytical abilities.
• Ability to learn quickly and multitask.
• Proficiency in maintaining good rapport with physicians, facilities, clients and providers.
• Concise written and verbal communication skills.
• Proficiency with Windows, Word, and Excel.

Responsibilities

• Process medical, dental, vision, and mental health claims daily.
• Perform claims processing and adjudication.
• Conduct claims research as needed.
• Verify medical necessity and coverage under policy guidelines.
• Meet or exceed production standards.
• Investigate and administer overpayments and track resolutions.
• Resolve claims appeals and verify benefits.

Skills

Analytical skills

Decision making

Communication

Multitasking

Microsoft Office

Education

High school diploma or GED

Some college courses

Tools

Microsoft Word

Excel

Claims processing system

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.