Claims Examiner I

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.

About the role

As a Claim Examiner, you will handle processing and adjudication for healthcare claims, including claims research where applicable and a range of claim complexity.

Schedule

Monday to Friday, 8:00am - 4:30pm Central Time for 4 weeks (training class start dates: 9/14/2026 and 10/12/2026).

Responsibilities

• Day-to-day processing of claims for accounts, including medical, dental, vision, and mental health claims.
• Claims processing and adjudication, including research where applicable.
• Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic).
• 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.
• Resolve claims appeals, research benefits, and verify correct plan loading.
• Review of multiple surgical procedures and establishment of reasonable and customary fees.

Requirements

• 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.
• 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, including the ability to handle conflict.
• Proficiency using Microsoft Windows, Word, Excel, and customized programs for medical CPT coding.
• Data entry and 10-key by touch/sight.

Preferred Qualifications

• Some college courses in related fields.
• Other experience in processing all types of medical claims.

Benefits

• Medical, dental, vision, life, and global travel health insurance.
• Income protection benefits: life insurance, short- and long-term disability programs.
• Flexible schedules after training.
• 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 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.

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.