Health Insurance Claims Adjudicator — Growth & Impact

Integrity; Clearwater (FL); On-site; USD 45,000 - 65,000; Full time

Job summary

Integrity is seeking an experienced claims adjudicator to analyze insurance claims and determine carrier liability. You will interpret contract benefits per guidelines and coordinate workflow to meet service guarantees.

The role requires 2–4 years of health insurance claims adjudication, familiarity with UB CMS-1450 and CMS-1500, and strong research and documentation skills. Travel may be minimal; strong communication is essential.

Qualifications

• 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

Responsibilities

• 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 elevate 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.

Skills

Claims adjudication

Health insurance

Education

High school diploma or GED

Tools

Qiclink software

Job description

Integrity is seeking an experienced claims adjudicator to analyze insurance claims and determine carrier liability. You will interpret contract benefits per guidelines and coordinate workflow to meet service guarantees.

The role requires 2–4 years of health insurance claims adjudication, familiarity with UB CMS-1450 and CMS-1500, and strong research and documentation skills. Travel may be minimal; strong communication is essential.