Claims Examiner I

GuideWell; San Antonio, Northern (TX, KY); Hybrid; USD 42,000 - 64,000; Full time

Benefits offered by this job

Medical, dental, vision insurance

Life and disability coverage

Flexible schedules after training

Leave programs

Retirement Savings Plan with employer

Paid time off and holidays

Wellness program

Job summary

WebTPA, a GuideWell Company, is seeking a Claim Examiner to handle processing and adjudication of healthcare claims. You will perform claims research, verify medical necessity, and ensure coverage according to policy guidelines.

Daily duties include processing medical, dental, vision, and mental health claims, investigating overpayments, and tracking resolutions. A 2+ year background in healthcare claims and strong analytical skills are required.

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 required.
• Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits.
• 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.
• Other experience in processing all types of medical claims helpful.
• Data entry and 10-key by touch/sight

Responsibilities

• Day-to-day processing of claims for accounts.
• Process 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.
• Incumbents are expected to meet and/or exceed qualitative and quantitative production standards.
• Investigate and overpayment administration: negotiate settlements and interpret medical records.
• Respond to Department of Insurance complaints and authorize payments.
• Overpayment reviews and recovery of claims overpayment; correct 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 coding

ICD-10 coding

Healthcare claims

Data entry

Multitasking

Communication skills

Education

High school diploma or GED

Some college coursework

Tools

Microsoft Excel

Microsoft Word

Claims processing systems

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:

• Anticipated Training Class Start Dates: 11/9/2026, 12/7/2026
• Schedule Monday to Friday 8:00am - 4:30pm CST 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:

• 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.

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-10 coding required.
• 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.
• 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.
• 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.