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

This is a full-time, in-office position located at 19100 Ridgewood Pkwy, San Antonio, TX 78259. Anticipated training class start date: 9/14/2026.

Schedule

• Monday to Friday, 8:00 AM – 4:30 PM Central Time for 4 weeks

Responsibilities

• Day-to-day processing of claims for accounts (medical, dental, vision, and mental health claims)
• Claims processing and adjudication, including claims 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

Qualifications

• Some college courses in related fields are a plus
• Other experience in processing all types of medical claims helpful

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 + future work-from-home 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 and a comprehensive wellness program

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.