Claims Adjuster I

Integrity; Clearwater (FL); Presencial; USD 42.000 - 65.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Competitive compensation package

Descripción de la vacante

Integrity is seeking an insurance claims adjudicator to analyze and adjudicate health insurance claims, interpreting contract benefits per specific guidelines.

The role involves organizing information on benefits, coordinating workflow with check cycles, and identifying potential fraud or waste. A high school diploma or GED is required, with 1 year of claims adjudication experience preferred; knowledge of UB/ CMS-1450 and HCFA/ CMS-1500 is expected.

Formación

• Requires high school diploma or GED.
• Minimum 1 year health insurance claims adjudication experience.
• Insurance background preferred; medical/prescription claims experience preferred.
• Experience with UB/institutional CMS-1450 and HCFA CMS-1500 claims required.
• Familiarity with medical terminology, procedures and diagnosis codes preferred.

Responsabilidades

• Analyze and adjudicate claims and inquiries.
• Organize and utilize information on benefits, coverage, and policy decisions.
• Interpret contract benefits per claims processing guidelines.
• Coordinate daily workflow to align with check cycles and service guarantees.
• Identify red flags for fraud or waste and escalate as needed.
• Investigate and document potential fraud or waste claims with system notes.

Conocimientos

Claims adjudication

Medical terminology

CMS-1450 (UB)

CMS-1500 (HCFA)

Qiclink

Microsoft Office

Deductible calculation

Communication

Documentation

Time management

Agent license (inactive)

Educación

High school diploma or GED

Herramientas

Qiclink software

Microsoft Office

Descripción del empleo

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 accelerate 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 equivalent
• Minimum 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 appointments

About Integrity

Integrity 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.