US CLAIMS MANAGER (NAPLES, FLORIDA)

Inova Care; Naples (FL); On-site; USD 90,000 - 130,000; Full time

Job summary

Inova Care in Naples, FL seeks a Claims Manager to lead adjudication across STM, ACA major medical, and supplemental products. You will ensure accurate, timely payments under plan documents and federal/state rules, applying the right rules to each product in a complex benefits landscape.

The ideal candidate brings strong knowledge of CPT/HCPCS/ICD-10-CM, HIPAA/ERISA, and No Surprises Act, plus Excel proficiency and proven leadership in fast-paced healthcare environments.

Qualifications

• Strong knowledge of medical and dental terminology and claims processing.
• Proficiency in CPT, HCPCS Level II, ICD-10-CM/PCS, CDT, revenue codes, modifiers, and place-of-service codes.
• Familiarity with CMS-1500, UB-04, and ADA claim forms.
• Understanding of UM criteria (InterQual/MCG), COB, and reimbursement methodologies (DRG, fee schedule, per diem, usual and customary).
• Knowledge of different plan types: ACA-compliant, indemnity, fixed-indemnity, self-funded vs fully insured.
• Knowledge of HIPAA, ERISA, No Surprises Act, and state insurance law.
• Strong analytical, problem-solving, and decision-making skills.
• Excellent written and verbal communication skills.
• Strong organizational skills and prioritization in fast-paced environment.
• Proficiency in Microsoft Office, especially Excel.
• Self-starter, results-oriented, with leadership ability.

Responsibilities

• Lead adjudication across STM, limited medical, ACA major medical, and other products to ensure correct payment.
• Ensure claims are paid accurately and on time under the correct plan document and laws.
• Apply the right rules to each product amidst differing benefit designs and regulations.
• Collaborate with examiners to implement HIPAA, ERISA, and No Surprises Act requirements.

Skills

Medical terminology

Dental terminology

Claims processing

CPT/HCPCS/ICD-10-CM

UB-04/CMS-1500

Revenue codes

CMS guidelines

HIPAA/ERISA/No Surprises Act

Analytical skills

Communication skills

Organizational skills

Excel

Leadership

Education

CPC-P

CPMA

AHFI

CHC

FLMI

Tools

Microsoft Excel

Job description

The Claims Manager leads adjudication across the company’s health portfolio: short-term medical (STM), limited medical, ACA-compliant major medical (individual and group), supplemental/specified-benefit products, Medicare Supplement, and dental and vision. The role ensures each claim is paid accurately and on time under the correct plan document, state insurance law, and federal rules for that product. Because benefit designs and regulations differ widely (reimbursement vs. indemnity, ACA-compliant vs. excepted benefits, fully insured vs. self-funded), the manager must make sure examiners apply the right rules to the right product.

Knowledge & Skills

• Strong knowledge of medical and dental terminology and claims processing.
• Proficiency in CPT, HCPCS Level II, ICD-10-CM/PCS, CDT, revenue codes, modifiers, and place-of-service codes; familiarity with CMS-1500, UB-04, and ADA claim forms.
• Working knowledge of UM criteria (InterQual/MCG), COB, and reimbursement methodologies (DRG, fee schedule, per diem, usual and customary).
• Understanding of the differences among reimbursement-based plans, fixed-indemnity/specified-benefit plans, ACA-compliant and excepted benefits, and fully insured vs. self-funded structures, plus HIPAA, ERISA, the No Surprises Act, and state insurance law.
• Strong analytical, problem-solving, and decision-making skills.
• Excellent written and verbal communication skills.
• Strong organizational skills and the ability to prioritize in a fast-paced environment.
• Proficiency in Microsoft Office, especially Excel.
• Self-starter, results-oriented, with demonstrated leadership ability.

Preferred

• CPC-P, CPMA, AHFI, or CHC; FLMI or similar insurance coursework a plus.