Health Insurance Claims Adjuster

Insurance Administrative Solutions•Clearwater, FL

7d•Onsite

About The Position

Insurance Administrative Solutions (IAS), an Integrity company headquartered in Clearwater, Florida, is a third-party administrator providing business process outsourcing for insurance carriers. IAS administers policies for insureds throughout the United States. The Health Insurance Claims Adjuster analyzes medical claims to determine the extent of an insurance carrier’s liability and interprets contract benefits in accordance with claims-processing guidelines. The role examines, researches, and adjudicates claims and written inquiries; uses information about benefits, contract coverage, and policy decisions; and coordinates workflow with check-cycle days to meet service guarantees. Adjusters identify and escalate potential fraud or waste. When assigned such cases, they investigate, track findings in clear and complete system notes, and report accurately and promptly. The position also connects the broader business strategy to daily claims-processing work and maintains external contact with providers, agents, and policyholders. The role begins fully onsite to support learning and team integration. Hybrid work opportunities may be introduced as proficiency is demonstrated, depending on business needs and department practices.

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, with 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 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.

Responsibilities

Examine, perform, and research claims and written inquiries, and make decisions needed to adjudicate them properly.
Receive, organize, and use information about benefits, contract coverage, and policy decisions in daily work.
Interpret contract benefits according to specific claims-processing guidelines.
Coordinate daily workflow with check-cycle days to meet service guarantees.
Recognize indicators of potential fraud or waste and escalate them as appropriate.
Investigate potential fraud or waste claims when assigned, track them with clear and complete system notes, and report accurately and promptly.
Understand the broad strategic concept of the business and connect it to day-to-day claims-processing functions.
Maintain external contact with providers, agents, and policyholders.