Claims Examiner I

GuideWell Source

. Process medical, dental, vision, and mental health claims for assigned accounts .

Posted 10/27/2026full-timeSan Antonio • 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-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 ProcessingCPT CodingICD-9 CodingHIPAA ComplianceDecision-Making Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AdjudicationClaims ResearchData Entry10-Key by Touch/SightMedical Necessity VerificationClaims Appeals ResolutionInsurance VerificationFinancial History CorrectionProduction Standards AchievementConflict Resolution

Soft Skills

Concise CommunicationJudgment SkillsMultitasking AbilityRapport Building

Tools & Technologies

Computerized Claims Payment SystemMicrosoft WindowsMicrosoft WordMicrosoft ExcelCustomized Medical Coding Programs

Industry Keywords

Healthcare IndustryCOBRAPre-Existing ConditionsCoordination of BenefitsDepartment of Insurance

About the role

Key responsibilities & impact

Process medical, dental, vision, and mental health claims for assigned accounts
Perform claims processing and adjudication across a range of claim complexity
Conduct claims research where applicable
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, and authorize payments to claimants and providers
Review and recover claim overpayments and correct patient and provider financial histories
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 and the ability to analyze
Ability to learn quickly and multitask
Ability to maintain good rapport with physicians, healthcare facilities, clients and providers
Concise written and verbal communication skills required, including the ability to handle conflict
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 are a plus
Other experience in processing all types of medical claims helpful
Data entry and 10-key by touch/sight

Benefits

Comp & perks

Medical, dental, vision, life and global travel health insurance
Income protection benefits: life insurance, Short- and long-term disability programs
Flexible schedules after training + future WAH options!
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 available
Comprehensive wellness program