Claims Examiner I (Remote)

WebTPA; United States; Remote; USD 42,000 - 58,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability benefits

Flexible schedule

WFH options

Leave programs

Retirement plan

Paid time off

Job summary

WebTPA, a GuideWell Company, a healthcare third-party administrator, seeks a Claims Examiner to handle processing and adjudication for healthcare claims. You will work on medical, dental, vision, and mental health claims, conducting research and ensuring coverage according to policy guidelines.

Position begins with anticipated training classes on 9/14/2026 or 10/12/2026, with a Monday–Friday schedule 8:00am–4:30pm CT for four weeks, and opportunities for flexible schedules after training and

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 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.

Responsibilities

• Day-to-day processing of claims for accounts (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.
• 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.

Skills

Claims adjudication

CPT ICD-10 coding

Healthcare regulations

MS Windows/Excel

Analytical/decision making

Strong communication

Education

High school diploma or GED

Diploma in related fields (preferred)

Tools

Claims processing system

Job description

US Remote

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: 9/14/2026 and 10/12/2026

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:

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:

• Diploma 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 + 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.