First Party Medical Claims Adjuster

GAINSCO•Richardson, TX

11d•Hybrid

About The Position

As a First Party Medical Claims Adjuster, you will process first-party medical claims across multiple states, ensuring accurate and timely payments in accordance with company guidelines. You will review medical bills and supporting documentation, respond to customer/provider inquiries, and help customers understand benefits and next steps throughout the medical claims process.

Requirements

High School Diploma or Equivalent.
Eligible to obtain a Texas or Florida Adjuster License. Upon hire, additional license(s) may be required and must be obtained.
Required license must be obtained by passing the applicable state exam within two (2) attempts.
All licenses must be maintained in accordance with state requirements.
Demonstrated success in customer service capacity.
Comfortable working in a fast-paced, high-volume call center.
Strong verbal and written communication skills.
Excellent attention to detail and organizational skills.
Ability to manage multiple tasks and prioritize effectively.
Analytical thinker with the ability to draw conclusions and make sound recommendations.
Calm and professional demeanor when handling challenging situations.
Eligible to lawfully work in the U.S. immediately; employer will not sponsor applicants for U.S. work authorization.

Nice To Haves

Active licensure is not required at the time of application or hire.
Professional Insurance and/or Claims Designations are a plus.
Experience in an insurance call center or claims operation preferred.
Experience with 1st Party Medical Claims is preferred.
Experience with medical coding and/or medical billing a plus.
Experience with Guidewire, Decision Point, and other claims systems preferred.

Responsibilities

Review and process reimbursement requests under first-party medical coverage (PIP/Med Pay), applying fee schedules, policy terms, co-pays, and deductibles.
Analyze claim documentation including medical bills/records, employment and wage info, and other supporting documents.
Respond promptly to inquiries from injured parties, medical providers, and attorneys (written and verbal).
Ensure PIP payment logs and requested claim/policy/payment information are provided within statutory timelines.
Support customers throughout the medical claims process by explaining benefits, eligibility, required forms/procedures, and claim status updates.