Claims Examiner I

GuideWell Source

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

Posted 9/25/2026full-timeRemote • Texas • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in claims processing and adjudication within the healthcare industry, with a strong understanding of CPT and ICD-10 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 ProcessingCPT CodingICD-10 CodingHIPAA ComplianceDecision-Making Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AdjudicationMedical Necessity VerificationData Entry10-Key by Touch/SightClaims Research

Soft Skills

Concise CommunicationConflict ResolutionRapport BuildingMultitaskingJudgment

Tools & Technologies

Microsoft WindowsMicrosoft WordMicrosoft ExcelCustomized Medical CPT Coding Programs

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

Healthcare IndustryCOBRACoordination of BenefitsPre-Existing ConditionsDepartment of Insurance

About the role

Key responsibilities & impact

Process medical, dental, vision, and mental health claims
Perform claims processing and adjudication across varying claim complexity
Research claims where applicable
Review and process insurance to verify medical necessity and coverage under policy guidelines
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 patient and service-provider financial histories
Track complaints and resolutions in relevant 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 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, 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

Benefits

Comp & perks

Medical, dental, vision, life and global travel health 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