Health Insurance Claims Adjudicator 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

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.