Claims Adjuster I

Insurance Administrative Solutions•Clearwater, FL

About The Position

Analyze claims to determine the extent of insurance carrier liability and interpret contract benefits in accordance with claim-processing guidelines. Examine, research, and adjudicate claims and written inquiries; organize and use information about benefits, contract coverage, and policy decisions; and coordinate daily workflow with check-cycle days to meet service guarantees. Recognize potential fraud or waste using established guidelines or historical knowledge and escalate concerns. When handling such claims, investigate and track them with clear, complete system notes and timely, accurate reporting. Understand how the company’s broader business strategy connects to daily claims-processing work and maintain external contact with providers, agents, and policyholders. Integrity describes itself as a leading independent distributor of life, health, and wealth insurance products, with an insurtech focus. The company says it offers a family-like, career-oriented environment, professional opportunities, and competitive compensation and benefits. Integrity is headquartered in Dallas, Texas, and is an equal opportunity employer that provides reasonable accommodations for qualified individuals with disabilities.

Requirements

High school diploma or GED equivalent.
At least 1 year of proven health insurance claims adjudication experience.
Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims.
Ability to read and interpret EOBs and claim history; excellent research skills.
Familiarity with Microsoft Office products.
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 multitask, prioritize, and manage time effectively and efficiently.
Reliable transportation and ability to be punctual and dependable.

Nice To Haves

Insurance background; previous medical or prescription claims experience preferred.
Familiarity with medical terminology, procedures, and diagnosis codes preferred.
Familiarity with Qiclink software is a plus.
May have an agent license, but no active appointments.

Responsibilities

Examine, research, and make decisions 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 with check-cycle days to meet service guarantees.
Recognize potential fraud or waste and escalate it as appropriate.
Investigate potential fraud or waste claims; track them with clear and complete system notes and provide accurate, timely reports on each file or case.
Connect the company’s broad strategic concepts to day-to-day claims-processing functions.
Maintain external contact with providers, agents, and policyholders.