Claims Examiner I at WebTPA

United States

<p><strong>Get To Know Us!</strong></p><p>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.</p><p><strong>Key position details:&nbsp;</strong></p><ul><li>Training Schedule: Monday to Friday 8:00am to 4:30pm Central Time</li><li>Training Duration: 4 weeks</li><li>Training Classes Starting: <strong>8/17/2026</strong></li><li>Full Time position</li></ul><p><strong>What is your impact?</strong><br>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.<strong>&nbsp;</strong></p><p><strong>What Will You Be Doing:&nbsp;</strong></p><ul><li>Day-to-day processing of claims for accounts:<ul><li>Responsible for processing of claims (medical, dental, vision, and mental health claims)</li><li>Claims processing and adjudication.</li><li>Claims research where applicable.&nbsp;</li><li>Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic).</li><li>Incumbents are expected to meet and/or exceed qualitative and quantitative production standards.</li></ul></li><li>Investigation and overpayment administration:<ul><li>Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers.</li><li>Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records.</li><li>Utilize systems to track complaints and resolutions.&nbsp;</li></ul></li><li>Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading.&nbsp;</li></ul><p><strong>What&nbsp;You Must&nbsp;Have:&nbsp;</strong></p><ul><li>2+ years related work experience.</li><li>Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry.</li><li>High school diploma or GED&nbsp;</li><li>Knowledge of CPT and ICD-10 coding required.&nbsp;</li><li>Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required.&nbsp;</li><li>Must possess proven judgment, decision-making skills and the ability to analyze.&nbsp;</li><li>Ability to learn quickly and multitask.</li><li>Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers.&nbsp;</li><li>Concise written and verbal communication skills required, including the ability to handle conflict.&nbsp;</li><li>Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding.&nbsp;</li><li>Review of multiple surgical procedures and establishment of reasonable and customary fees.</li></ul><p><strong>What We Prefer:&nbsp;</strong></p><ul><li>Some college courses in related fields are a plus.</li><li>Other experience in processing all types of medical claims helpful.&nbsp;</li><li>Data entry and 10-key by touch/sight&nbsp;</li></ul><p>General Physical Demands:&nbsp; Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.&nbsp;</p><p>Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.&nbsp;<br><br><i><strong>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.</strong></i></p>