Claims Adjudicator

Independent Health; United States; Hybrid; USD 32,000 - 44,000; Full time

Benefits offered by this job

Scorecard incentive

Benefits package

Generous paid time off

Job summary

Independent Health in United States is seeking a Claims Adjudicator to adjudicate medical and dental claims against established criteria and SPD goals. You will respond to inquiries about claim status, benefits, and payments in collaboration with Customer Service.

This role requires attention to detail, strong communication, and the ability to work with internal and external customers. Flexibility for additional hours and a collaborative mindset are essential.

Qualifications

• High school diploma required; medical office assistant certificate and/or college degree preferred.
• 6+ months of medical claims processing/billing or healthcare customer service experience.
• Knowledge of medical billing procedures, CPT and ICD-9 coding, and medical terminology.
• Proficiency with data entry and Microsoft Office products.
• Strong organizational, written and verbal communication skills.
• Ability to collaborate and communicate with internal and external customers.
• Flexibility to work additional hours as needed.
• Demonstrated alignment with Nova’s Core 4: Act with Passion, Work Together, Be Accountable, Build Trust.

Responsibilities

• Adjudicate claims based on policies for facility, professional, member-submitted, pharmacy, and dental edits.
• Review vouchers/explanations of payments to resolve claim issues.
• Meet department performance measures for production, accuracy, and timeliness.
• Analyze and research edits showing policy, payment, or coding inconsistencies.
• Maintain current contract, SPD, and benefit knowledge.
• Adhere to deadlines and regulatory compliance.
• Use critical-thinking to process claims efficiently.
• Navigate systems to locate information for claim scenarios.
• Identify opportunities for process improvements.
• Prioritize and manage claim-processing workload.
• Communicate with other departments to resolve payment issues.

Skills

Medical billing procedures

CPT / ICD-9 coding

Data entry

Microsoft Office

Communication skills

Organizational skills

Team collaboration

Flexibility

Core 4 values alignment

Education

High school diploma

Medical office assistant certificate

College degree (preferred)

Tools

Microsoft Office

Job description

Overview

The Claims Adjudicator is responsible for adjudicating and adjusting medical and/or dental claims against established criteria and specific client SPD goals in accuracy and productivity. The role also includes responding to client, member, and/or provider inquiries on claim status, benefit designs, and claim payments in conjunction with the Customer Service Representative.

Qualifications

• High school diploma required; medical office assistant certificate and/or college degree preferred.
• At least six (6) months of medical claims processing/medical billing experience, or customer service experience preferably in a healthcare related or social services setting; OR combination of experience.
• Knowledge of medical billing procedures, CPT and ICD-9 coding, and medical terminology.
• Proficiency with data entry and Microsoft Office products.
• Organizational skills with attention to detail and follow‑through.
• Good written, verbal, and interpersonal communication skills.
• Ability to communicate effectively with internal and external customers.
• Collaborative working style.
• Flexibility to work additional hours as needed.
• Demonstrated ability to embody Nova’s Core 4: Act with Passion, Work Together, Be Accountable, Build Trust.

Essential Accountabilities

• Adjudicate claims based on established policies and procedures for facility, professional, member‑submitted, pharmacy, and dental claim edits, including in‑ and out‑of‑network benefits.
• Review vouchers/explanations of payments to identify and resolve claim–related issues.
• Consistently meet department performance measures related to production, accuracy, policy knowledge, and timeliness of claims adjudication.
• Analyze, identify, and research edits that demonstrate inconsistencies in policy, payment, or coding.
• Maintain current contract, summary plan description, and benefit knowledge.
• Adhere to departmental deadlines, turnaround times, and compliance with state and federal regulations.
• Utilize critical‑thinking skills to process claims efficiently.
• Navigate systems and applications to locate information specific to claim scenarios.
• Accurately locate resources and interpret and apply appropriate information to various claim scenarios.
• Identify and communicate process opportunities or improvements.
• Prioritize and manage claim‑processing workload efficiently.
• Communicate effectively with other departments within Independent Health to resolve problems related to claim payment.

Compensation

Hiring compensation range: $18.00 per hour. Compensation may vary based on skills, education, location, and experience. In addition to base compensation, associates may be eligible for a scorecard incentive, a full range of benefits, and generous paid time off. The base salary range is subject to change and may be modified in the future.

Visa and Sponsorship

Immigration or work‑visa sponsorship will not be provided for this position.

EEO Statement

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled veteran, special, recently separated, active‑duty wartime, campaign badge, ArmedForces service medal veteran, or any other characteristics protected under applicable law.