Claims Examiner

Overview

WebTPA, a Guide Well Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans.

• Full time, in office: 19100 Ridgewood Pkwy, San Antonio, TX 78259
• Schedule:
  
  Monday to Friday 8:00am – 4:30pm Central Time (4 weeks)
• Training Class
  
  Start Date:
  
  2/2 or 3/2

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

• Day‑to‑day processing of claims for accounts (medical, dental, vision, and mental health claims)
• Claims processing and adjudication
• Claims research where applicable
• Review and process 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 over payment; correct financial histories of patients and service providers to ensure accurate records
• Utilize systems to track complaints and resolutions
• Resolve claims appeals, research benefits, verify correct plan loading

• 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
• Knowledge of COBRA, HIPAA, pre‑existing conditions, and coordination of benefits
• Proven judgment, decision‑making skills and 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 conflict handling
• Proficiency using Microsoft Windows and Word, Excel, and customized programs for medical CPT coding
• Review of multiple surgical procedures and establishment of reasonable and customary fees

• Some college courses in related fields
• Other experience in processing all types of medical claims
• Data entry and 10-key by touch/sight

• 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 and 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.

Entry level

Full‑time

Finance and Sales

Insurance