Claims Adjuster I

Integrity Marketing Group; Clearwater (FL); On-site; USD 42,000 - 68,000; Full time

Job summary

Integrity Marketing Group is seeking a Claims Adjudicator to analyze insurance claims and determine carrier liability. The role involves interpreting benefits per guidelines, coordinating daily workflows, and flagging potential fraud or waste.

Strong research, EOB reading, and communication skills are required. You will handle UB/institutional and CMS-1450/CMS-1500 claims, work with MS Office, and maintain records and provider contacts.

Qualifications

• 1+ year proven health insurance claims adjudication experience.
• Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims.
• Familiarity with medical terminology and diagnosis codes.
• Excellent research and documentation skills; strong communication.

Responsibilities

• Examine, perform, research and determine adjudication decisions for claims and inquiries.
• Receive, organize and use information on benefits, contracts and policy decisions.
• Interpret contract benefits per specific claims guidelines.
• Coordinate daily workflow to align with check cycle days and service guarantees.
• Identify red flags for potential fraud or waste and escalate as needed.
• Investigate and document files; maintain clear system notes and timely reporting.
• Understand broad business concepts and link to day-to-day claims processing.
• Maintain external contacts with providers, agents and policyholders.

Skills

Claims adjudication

Medical terminology

Communication skills

EOB interpretation

Office software

Education

High school diploma or GED

Tools

CMS-1450

CMS-1500

Qiclink

MS Office

Job description

Job Summary: Analyze claims to determine the extent of insurance carrier liability. Interpret contract benefits in accordance with specific claims processing guidelines.Primary Responsibilities other duties may be assigned as necessary:Examine/perform/research & make decisions necessary to properly adjudicate claims and written inquiries.Receive, organize and make daily use of information regarding benefits, contract coverage, and policy decisions.Interpret contract benefits in accordance with specific claim processing guidelines.Coordinate daily workflow to coincide with check cycle days to meet all service guarantees.Based on established guidelines and/or historical knowledge an adjuster will need to recognize red flags for potential fraud or waste and escalate accordingly.Adjusters who handle the potential fraud or waste claims will investigate, track via clear and complete system notes and accurately report on each file/case in a timely manner.Understand broad strategic concept of our business and link these to the day-to-day business functions of claims processing.Maintain external contact with providers/agents/policyholders.Primary Skills & Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.A high school diploma or GED equivalentMinimum of 1 year proven health insurance claims adjudication experience.Insurance background preferred; previous Medical/prescription claims preferred.Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims required.Familiarity with medical terminology, procedures and diagnosis codes preferred.Ability to read and interpret EOB’s claim history, and excellent research skills.Familiarity with Microsoft Office products; familiarity with Qiclink software a plus.Ability to calculate deductible and co-insurance amounts.Ability to adapt and respond to different types of people and tasks.Excellent communication and documentation skills.Ability to multi-task, prioritize, and manage time effectively and efficiently.Reliable transportation and the ability to be punctual and dependable.May have agent license but no active appointmentsAbout IntegrityIntegrity is one of the nation’s leading independent distributors of life, health and wealth insurance products. With a strong insurtech focus, we embrace a broad and innovative approach to serving agents and clients alike. Integrity is driven by a singular purpose: to help people protect their life, health and wealth so they can prepare for the good days ahead.Integrity offers you the opportunity to start a career in a family-like environment that is rewarding and cutting edge. Why? Because we put our people first! At Integrity, you can start a new career path at company you’ll love, and we’ll love you back. We’re proud of the work we do and the culture we’ve built, where we celebrate your hard work and support you daily. Joining us means being part of a hyper-growth company with tons of professional opportunities for you to accelerate your career. Integrity offers our people a competitive compensation package, including benefits that make work more fun and give you and your family peace of mind.Headquartered in Dallas, Texas, Integrity is committed to meeting Americans wherever they are — in person, over the phone or online. Integrity’s employees support hundreds of thousands of independent agents who serve the needs of millions of clients nationwide. For more information, visit Integrity.com.Integrity, LLC is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, disability, veteran status, or any other characteristic protected by federal, state, or local law. In addition, Integrity, LLC will provide reasonable accommodations for qualified individuals with disabilities.