Medical Health Insurance Claims Adjuster

Integrity Marketing Group; United States; Remote; USD 52,000 - 68,000; Full time

Benefits offered by this job

Medical/Dental/Vision Insurance

401(k) Retirement Plan

Paid Holidays

PTO

Community Service PTO

FSA/HSA

Life Insurance

Short-Term and Long-Term Disability

Job summary

Insurance Administrative Solutions, L.L.C. (IAS), an Integrity company, seeks a Health Insurance Claims Adjuster in Clearwater, FL to analyze medical claims and determine carrier liability under specific guidelines.

You will interpret benefits, organize information, and coordinate daily workflows while maintaining accurate notes and communicating with providers, agents, and policyholders. The role begins onsite with potential for hybrid work as proficiency grows.

Qualifications

• Minimum 1 year proven health insurance claims adjudication experience.
• Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims.
• Familiarity with medical terminology, procedures and diagnosis codes.
• Ability to read and interpret EOBs and claim histories.
• Strong research and documentation skills.

Responsibilities

• Examine, adjudicate claims and inquiries to determine carrier liability.
• Organize and use information regarding benefits, coverage and policy decisions.
• Interpret contract benefits per specific claims processing guidelines.
• Coordinate daily workflow with check cycle days to meet service guarantees.
• Recognize red flags for potential fraud or waste and escalate accordingly.
• Investigate, document and report on each file with clear system notes.
• Understand the business concepts and connect them to day-to-day claims processing.
• Maintain external contact with providers, agents and policyholders.

Skills

Health insurance claims adjudication

Communication skills

Documentation

Reading EOBs

Multi-tasking

Time management

Research skills

Education

High school diploma or GED

Tools

Microsoft Office

Qiclink software

Job description

Health Insurance Claims Adjuster

Insurance Administrative Solutions

Clearwater, FL

About Insurance Administrative Solutions

Insurance Administrative Solutions, L.L.C. (“IAS”), an Integrity company headquartered in Clearwater, Florida, is a third‑party administrator providing business process outsourcing for insurance carriers. Formed in 2002, IAS administers policies for insureds residing all across the United States.

Job Summary

Analyze medical 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 escalates 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

• 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.

Benefits Available

• We value flexibility and recognize the importance of work‑life balance. This role will begin as fully onsite to support learning and team integration. As proficiency is demonstrated, hybrid work opportunities may be introduced, dependent on business needs and department practices.
• Medical/Dental/Vision Insurance
• 401(k) Retirement Plan
• Paid Holidays
• PTO
• Community Service PTO
• FSA/HSA
• Life Insurance
• Short-Term and Long-Term Disability

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.