Health Insurance Claims Adjuster

Insurance Administrative Solutions•Clearwater, FL

1d•Onsite

About The Position

Analyze claims to determine the extent of insurance carrier liability. Interpret contract benefits in accordance with specific claims processing guidelines. This role involves examining, researching, and making decisions to properly adjudicate claims and written inquiries. The adjuster will organize and utilize information regarding benefits, contract coverage, and policy decisions, coordinating daily workflow to meet service guarantees. Recognizing and escalating potential fraud or waste is a key responsibility, which may include investigation, tracking, and reporting. The position requires understanding the broad strategic concept of the business and linking it to daily claims processing functions, as well as maintaining external contact with providers, agents, and policyholders.

Requirements

A high school diploma or GED equivalent
Minimum of 1 year proven health insurance claims adjudication experience.
Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims required.
Ability to read and interpret EOB’s claim history, and 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 multi-task, 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/prescription claims preferred.
Familiarity with medical terminology, procedures and diagnosis codes preferred.
familiarity with Qiclink software a plus.

Responsibilities

Examine/perform/research & make decisions necessary 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 to coincide with check cycle days to meet all service guarantees.
Recognize red flags for potential fraud or waste and escalate accordingly.
Investigate, track via clear and complete system notes and accurately report on each file/case in a timely manner for potential fraud or waste claims.
Understand broad strategic concept of our business and link these to the day-to-day business functions of claims processing.
Maintain external contact with providers/agents/policyholders.