Claims Examiner I

GuideWell Source

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

Posted 10/27/2026full-timeRemote • Texas • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in processing and adjudicating medical claims, including knowledge of CPT and ICD-9 coding, while maintaining compliance with HIPAA and COBRA regulations. Proven ability to analyze claims, negotiate settlements, and communicate effectively with healthcare providers and clients.

Highest-signal resume keywords

Claims Adjudication ExperienceKnowledge Of CPT And ICD-9 CodingProficiency In Microsoft Word And ExcelJudgment And Decision-Making SkillsAbility To Analyze And Multitask

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingMedical Claims AdjudicationCPT CodingICD-9 CodingClaims ResearchClaims InvestigationsData Entry10-Key By Touch/SightFinancial History CorrectionClaims Appeals Resolution

Soft Skills

Concise Communication SkillsAbility To Handle ConflictRapport BuildingJudgmentDecision-Making

Tools & Technologies

Computerized Claims Payment SystemMicrosoft WindowsMicrosoft WordMicrosoft ExcelCustomized Medical CPT Coding Programs

Certifications & Qualifications

High School Diploma Or GED

Industry Keywords

Healthcare IndustryHIPAACOBRACoordination Of BenefitsMedical NecessityInsurance CoverageDepartment Of InsurancePre-Existing ConditionsQualitative And Quantitative StandardsSurgical Procedures

About the role

Key responsibilities & impact

Process and adjudicate medical, dental, vision, and mental health claims
Conduct claims research where applicable across varying claim complexity
Review and process insurance to verify medical necessity and coverage under policy guidelines using clinical edit logic
Meet 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 designated 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-9 coding required
Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required
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 the ability to handle conflict
Proficiency using Microsoft Windows and Word, Excel, and customized medical CPT coding programs
Ability to review multiple surgical procedures and establish reasonable and customary fees
Some college courses in related fields are a plus
Other experience processing all types of medical claims is helpful
Data entry and 10-key by touch/sight

Benefits

Comp & perks

Medical, dental, vision, life and global travel health insurance
Short- and long-term disability programs
Flexible schedules after training
Work-at-home options after training
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