Health Insurance Claims Adjuster-2

Integrity•Clearwater, FL

About The Position

Analyze health insurance claims to determine the extent of the insurance carrier’s liability and interpret contract benefits in accordance with claims-processing guidelines. The adjuster examines, researches, and adjudicates claims and written inquiries, using information about benefits, contract coverage, and policy decisions. The role also includes coordinating daily workflow around check-cycle days to meet service guarantees and recognizing and escalating potential fraud or waste. Adjusters handling such cases investigate them, maintain clear and complete system notes, and report accurately and promptly. In addition to the claim types initially learned, the adjuster is expected to handle most claim types within the department 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. It offers a family-like work environment, professional opportunities, and a competitive compensation package that includes benefits; specific benefits are not listed. Integrity, LLC is an Equal Opportunity employer and 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, with 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, research, and make decisions needed to properly adjudicate claims and written inquiries.
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 and escalate potential fraud or waste based on established guidelines or historical knowledge.
Investigate potential fraud or waste claims; track them with clear, complete system notes and report accurately and promptly on each file or case.
Understand the broad strategic concepts of the business and connect them to day-to-day claims-processing work.
Handle the majority of claim types within the department in addition to initially trained claim types.
Maintain external contact with providers, agents, and policyholders.