Health Insurance Claims Adjuster-2

Integrity Marketing Group•Clearwater, FL

About The Position

Analyze claims to determine the extent of insurance carrier liability and interpret contract benefits in accordance with specific claims processing guidelines. Examine, perform, and research claims and written inquiries, making decisions necessary to adjudicate them properly. Organize and use information about benefits, contract coverage, and policy decisions. Coordinate daily workflow with check-cycle days to meet service guarantees. Recognize and escalate potential fraud or waste based on established guidelines or historical knowledge. For claims involving potential fraud or waste, investigate, track activity through clear and complete system notes, and report accurately and promptly on each file or case. Understand the company’s strategic business concepts and connect them to day-to-day claims processing. Handle the claims initially trained on as well as the majority of claim types within the department. Maintain external contact with providers, agents, and policyholders. Integrity is an independent distributor of life, health, and wealth insurance products with an insurtech focus. The company describes its purpose as helping people protect their life, health, and wealth, and offers a family-like environment with professional opportunities. It provides a competitive compensation package 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.
Two to four years 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 coinsurance 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 the ability to be punctual and dependable.

Nice To Haves

Insurance background preferred.
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, perform, and research claims and written inquiries, and make decisions to adjudicate them properly.
Receive, organize, and use information regarding benefits, contract coverage, and policy decisions.
Interpret contract benefits according to specific claims 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, document them with clear and complete system notes, and report accurately and promptly on each file or case.
Connect the company’s broad strategic concepts to day-to-day claims processing.
Handle the claims initially trained on and the majority of claim types within the department.
Maintain external contact with providers, agents, and policyholders.