Claims Examiner I

GuideWell Source

Claims Examiner processing healthcare claims for WebTPA. Handling adjudication, investigation, and overpayment administration while ensuring quality standards.

Posted 5/18/2026full-timeRemote • Texas • 🇺🇸 United StatesJuniorMid-LevelWebsite

About the role

Key responsibilities & impact

Day-to-day processing of claims for accounts:
Responsible for processing of claims (medical, dental, vision, and mental health claims)
Claims processing and adjudication.
Claims research where applicable.
Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic).
Investigation and overpayment administration:
Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers.
Other responsibilities include resolving claims appeals, researching benefits, verifying 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.
Must possess proven judgment, decision-making skills and the ability to analyze.
Ability to learn quickly and multitask.
Proficiency in maintaining 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.

Benefits

Comp & perks

25 days annual leave
Health insurance
Flexible work arrangements

ATS Keywords

✓ Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

claims processingclaims adjudicationCPT codingICD-10 codingmedical necessity verificationclaims researchoverpayment administrationnegotiationbenefits researchplan loading verification

Soft Skills

judgmentdecision-makinganalytical skillsmultitaskingrapport buildingcommunication skillsconflict resolution

Certifications

high school diplomaGED