Claims Examiner I

WebTPA; San Antonio, Northern (TX, KY); On-site; USD 42,000 - 64,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability benefits

Retirement plan with employer match

Paid time off and holidays

Flexible schedules after training

Job summary

WebTPA, a GuideWell Company, is hiring a Claim Examiner in San Antonio, TX to handle processing and adjudication of healthcare claims. You will perform claims research, verify medical necessities, and ensure accurate policy coverage.

The role requires 2+ years in claims adjudication, ICD/CPT coding knowledge, and strong communication with healthcare providers. On-site hours are Mon-Fri 8:00am-4:30pm CST after training.

Qualifications

• 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-9 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.
• 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 complaints, and authorize payment to claimants and providers.
• Overpayment reviews and recovery of claims overpayment; correct financial histories of patients and providers.
• Utilize systems to track complaints and resolutions.
• Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading.

Skills

CPT/ICD-9 coding knowledge

Healthcare claims adjudication

Microsoft Office (Word/Excel)

Communication skills

HIPAA compliance

Analytical decision making

Multitasking ability

Interpersonal with providers

Education

High school diploma or GED

Tools

Medical CPT coding software

Job description

• Locations San Antonio, TX, United States (On-site)

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.

• This is a Full time in office position: 19100 Ridgewood Pkwy San Antonio, TX 78259
• Anticipated Training Class Start Dates: 9/14/2026
• Schedule Monday to Friday 8:00am - 4:30pm Central Time for 4 weeks

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:

The essential functions listed represent the major duties of this role, additional duties may be assigned.

• 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.

WhatYou MustHave:

• 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-9 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

What We Can Offer YOU!

To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, Short- and long-term disability programs
• Flexible schedules after training + future WAH options!
• Leave programs to support personal circumstances.
• Retirement Savings Plan includes employer contribution and employer match
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ.

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.

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.