Claims Adjuster II

Insurance Administrative Solutions, L.L.C.; Clearwater (FL); On-site; USD 52,000 - 76,000; Full time

Job summary

Integrity LLC in Clearwater, FL is seeking a Claims Adjuster II to analyze claims, interpret benefits, and adjudicate liability in line with specific processing guidelines. You will manage daily workflows and coordinate with providers, agents, and policyholders to ensure timely service.

The role requires health insurance claims adjudication experience, knowledge of CMS-1450/ CMS-1500 claims, and strong documentation skills.

Qualifications

• A high school diploma or GED equivalent.
• Two to four years of 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 EOBs, 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.
• Reliable transportation and the ability to be punctual and dependable.
• May have agent license but no active appointments

Responsibilities

• Analyze claims to determine liability and adjudicate accordingly.
• Interpret benefits per claims guidelines and contract terms.
• Maintain daily workflow to meet service guarantees.
• Escalate potential fraud or waste with clear notes.
• Interact with providers, agents, and policyholders.
• Document thoroughly in the system.
• Handle multiple claim types within the department.

Skills

Health insurance claims adjudication

Medical terminology knowledge

EOB interpretation

Documentation skills

Communication skills

Fraud awareness

Education

High school diploma or GED

Tools

UB/CMS-1450 claims

CMS-1500 claims

Qiclink software

Microsoft Office

Job description

Claims Adjuster II### Claims Adjuster IIApply: Clearwater, FL: Full time: Posted Yesterday: JR4996**Job Summary:** Analyze claims to determine the extent of insurance carrier liability. Interpret contract benefits in accordance with specific claims processing guidelines.**Primary Skills & Requirements** *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 decision.* 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.* In addition to being able to handle the initial claims that they were trained on, they will be able to handle the majority of claim types within the department.* 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 .* Two to four years of 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.*