Claims Examiner I

GuideWell Source

. Process and adjudicate medical, dental, vision, and mental health claims .

Posted 10/12/2026full-timeRemote • Texas • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in processing and adjudicating medical claims, with a strong understanding of CPT and ICD-10 coding, as well as compliance with HIPAA and COBRA regulations. Proven ability to analyze complex claims, negotiate settlements, and maintain effective communication with healthcare providers and clients.

Highest-signal resume keywords

Claims Adjudication ExperienceCPT and ICD-10 Coding KnowledgeHIPAA ComplianceMicrosoft Excel ProficiencyDecision-Making Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingMedical Record InterpretationData Entry10-Key by Touch/SightClaims InvestigationsOverpayment RecoveryInsurance VerificationBenefits ResearchClaims Appeals ResolutionNegotiation Skills

Soft Skills

Concise CommunicationConflict ResolutionJudgment SkillsMultitasking AbilityRapport Building

Tools & Technologies

Computerized Claims Payment SystemMicrosoft WindowsMicrosoft WordCustomized Medical CPT Coding Programs

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

Healthcare IndustryCOBRAPre-Existing ConditionsCoordination of BenefitsDepartment of Insurance

About the role

Key responsibilities & impact

Process and adjudicate medical, dental, vision, and mental health claims
Research claims where applicable across varying levels of complexity
Review and process insurance to verify medical necessity and coverage under policy guidelines using clinical edit logic
Meet and/or exceed qualitative and quantitative production standards
Facilitate claims investigations
Negotiate settlements
Interpret medical records
Respond to Department of Insurance complaints
Authorize payments to claimants and providers
Review and recover claims overpayments
Correct financial histories of patients and service providers
Track complaints and resolutions using systems
Resolve claims appeals
Research benefits
Verify correct plan loading

Requirements

What you’ll need

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-10 coding required
Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits
Proven judgment and decision-making skills
Ability to analyze, learn quickly, and multitask
Ability to maintain good rapport with physicians, healthcare facilities, clients, and providers
Concise written and verbal communication skills, including ability to handle conflict
Proficiency using Microsoft Windows and Word, Excel, and customized medical CPT coding programs
Experience reviewing multiple surgical procedures and establishing reasonable and customary fees
Data entry and 10-key by touch/sight

Benefits

Comp & perks

Medical, dental, vision, life and global travel health insurance
Life insurance
Short- and long-term disability programs
Flexible schedules after training
Future work-at-home options
Leave programs to support personal circumstances
Retirement Savings Plan with employer contribution and employer match
Paid time off
Volunteer time off
11 holidays
Additional voluntary benefits
Comprehensive wellness program