Claims Examiner I

GuideWell Source

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

Posted 11/4/2026full-timeRemote • Texas • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in processing and adjudicating medical claims, with a strong understanding of CPT and ICD-9 coding, as well as compliance with HIPAA and COBRA regulations. Proven ability to analyze claims, negotiate settlements, and maintain effective communication with healthcare providers and clients.

Highest-signal resume keywords

Claims Adjudication ExperienceKnowledge Of CPT And ICD-9 CodingProficiency In Microsoft Windows, Word, 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 Necessity VerificationClaims InvestigationsData Entry10-Key By Touch/SightClaims Appeals ResolutionFinancial History CorrectionBenefit ResearchPlan Loading VerificationSettlement Negotiation

Soft Skills

Concise Communication SkillsAbility To Handle ConflictRapport Building

Tools & Technologies

Computerized Claims Payment SystemCustomized Medical CPT Coding Programs

Certifications & Qualifications

High School Diploma Or GED

Industry Keywords

Healthcare IndustryCOBRAHIPAAPre-Existing ConditionsCoordination Of Benefits

About the role

Key responsibilities & impact

Process and adjudicate medical, dental, vision, and mental health claims
Research claims where applicable across a range of claim complexity
Review and process insurance to verify medical necessity and coverage under policy guidelines and 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 claim 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 ability to handle conflict
Proficiency using Microsoft Windows, Word, Excel, and customized medical CPT coding programs
Ability to review multiple surgical procedures and establish reasonable and customary fees
Data entry and 10-key by touch/sight
Some college courses in related fields are a plus
Other experience processing all types of medical claims is helpful

Benefits

Comp & perks

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