Claims Examiner

Independent Living Systems, llc; Miami (FL); On-site; USD 42,000 - 65,000; Full time

Job summary

Independent Living Systems is seeking a Claims Examiner in Miami, FL to thoroughly review and evaluate insurance claims for accuracy and compliance. You will analyze medical documentation, policy terms, and billing data to determine validity, collaborating with providers and internal teams to resolve issues and ensure timely reimbursement.

The role requires 2+ years in claims/exam, familiarity with ICD-10/CPT, and proficiency in claims software and MS Office.

Qualifications

• High school diploma or GED required.
• At least 2 years in claims examination, medical billing, or healthcare insurance processing.
• Strong understanding of medical terminology, insurance policies, and healthcare billing codes (ICD-10, CPT).
• Proficiency with claims management software and Microsoft Office suite.

Responsibilities

• Review health insurance claims for completeness, accuracy, and policy compliance.
• Verify medical codes, documentation, and billing details to ensure proper coverage.
• Investigate discrepancies by communicating with providers and internal teams.
• Escalate potential fraud or billing errors to compliance or legal teams.
• Maintain detailed records to support audits and improve workflows.

Skills

Medical terminology

Insurance policies

Billing codes

Attention to detail

Education

Associate’s or Bachelor’s degree in health administration/healthcare management

CPC or CCP certification (preferred)

Tools

Claims management software

Microsoft Office

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Full Time Professional Miami, FL, US

3 days ago Requisition ID: 3290

We are seeking a Claims Examiner to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

About the Role:

The Claims Examiner plays an essential role by thoroughly reviewing and evaluating insurance claims to ensure accuracy, compliance, and appropriateness of payments. This position involves analyzing medical documentation, policy details, and billing information to determine the validity of claims and identify any discrepancies or potential fraud. The Claims Examiner collaborates with healthcare providers, and internal teams to resolve claim issues and facilitate timely reimbursement. By maintaining up-to-date knowledge of healthcare regulations and insurance policies, the Claims Examiner helps protect the organization from financial loss and supports the delivery of fair and efficient claims processing. Ultimately, this role contributes to the integrity and sustainability of the organization by ensuring claims are processed accurately and ethically.

Minimum Qualifications:

• High school diploma or GED.
• Minimum of 2 years experience in claims examination, medical billing, or healthcare insurance processing.
• Strong understanding of medical terminology, insurance policies, and healthcare billing codes (e.g., ICD-10, CPT).
• Proficiency with claims management software and Microsoft Office suite.

Preferred Qualifications:

• Associate’s degree or Bachelor's degree in health administration, healthcare management, or a related discipline.
• Certification such as Certified Professional Coder (CPC) or Certified Claims Professional (CCP).
• Experience working within the health care and social assistance industry or with government healthcare programs.
• Familiarity with regulatory frameworks such as HIPAA and the Affordable Care Act.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Review and analyze health insurance claims for completeness, accuracy, and compliance with policy terms and regulatory requirements.
• Verify medical codes, treatment documentation, and billing information to ensure services are properly covered and billed.
• Investigate and resolve claim discrepancies by communicating with providers and internal stakeholders.
• Identify and elevate potential fraudulent claims or billing errors to compliance or legal teams.
• Maintain detailed records of claim evaluations and stay current with healthcare laws and industry standards to support audits and improve processing workflows.