Claims Examiner I

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: 

This is a Full time in office position at either office location: 

6535 SH-161, Irving, Texas 75039

19100 Ridgewood Pkwy San Antonio, TX 78259

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 (80%):
  • 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 (10%):
  • 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. (10%)

What You Must Have: 

• 2+ years related medical claims examiner/adjudication experience 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. 
• Must possess proven judgment, decision-making skills and the ability to analyze. 

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
• 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. 

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.

At GuideWell, we're passionate about building a workplace culture where everyone feels valued and empowered to succeed. We're committed to creating an environment that values and respects the unique perspectives and experiences of all our employees. Our mission is to help people and communities achieve better health, and we believe that everyone's contribution has the power to make a difference. Join our team and help us achieve our mission of helping people and communities achieve better health.