Claims Examiner I

About the Company

WebTPA, a GuideWell Company, has over three decades of expertise as a healthcare third-party administrator, specializing in creating tailored benefit solutions and managing customized health plans.

Training Details

• Schedule: Monday to Friday, 8:00 AM to 4:30 PM Central Time
• Duration: Four weeks
• Training Start Date: August 17, 2026
• Position Type: Full-time

Role Overview

As a Claims Examiner, you will be responsible for processing and adjudicating healthcare claims encompassing medical, dental, vision, and mental health services. Your duties will include conducting claim research when necessary and handling a variety of claim complexities.

Key Responsibilities

• Process daily claims for various accounts and ensure timely adjudication
• Verify insurance coverage and medical necessity using clinical edit logic
• Perform claims investigation, negotiate settlements, interpret medical records, and address Department of Insurance complaints
• Manage overpayment reviews and facilitate recovery, maintaining accurate financial records for patients and providers
• Track complaints and resolutions using designated systems
• Handle claim appeals, research benefits, and confirm correct plan loading

Required Qualifications

• Minimum of two years relevant experience processing claims in healthcare
• Hands-on experience with computerized claims payment systems
• High school diploma or GED mandatory
• Proficiency in CPT and ICD-10 medical coding
• Comprehensive understanding of COBRA, HIPAA compliance, pre-existing conditions, and coordination of benefits
• Strong analytical and decision-making capabilities
• Ability to quickly learn and multitask efficiently
• Competency in professional interaction with physicians, healthcare facilities, clients, and providers
• Effective written and verbal communication skills, including conflict resolution
• Familiarity with Microsoft Windows, Word, Excel, and custom medical CPT coding tools
• Skill in reviewing multiple surgical procedures and setting reasonable customary fees

Preferred Qualifications

• Some college coursework in relevant fields
• Additional experience in processing varied types of medical claims
• Data entry proficiency and 10-key by touch or sight

Physical Demands

This role involves primarily sedentary work with occasional exertion of up to ten pounds of force.

Equal Opportunity Employment

The company is an Equal Employment Opportunity employer dedicated to fostering an inclusive environment where all employees can thrive and contribute towards the mission.