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Health Insurance Claims Adjuster
Integrity Marketing Group LLC. Analyze medical claims to determine the extent of insurance carrier liability .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Proficient in analyzing medical claims and adjudicating health insurance claims with a strong understanding of contract benefits and claims processing guidelines. Demonstrates excellent research, communication, and documentation skills while effectively managing workflow and identifying potential fraud.
Highest-signal resume keywords
Health Insurance Claims AdjudicationUB/Institutional Claims (CMS-1450)HCFA/Professional Claims (CMS-1500)Medical Terminology FamiliarityMicrosoft Office Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AnalysisContract Benefit InterpretationFraud InvestigationEOB Reading and InterpretationDeductible and Co-Insurance Calculation
Soft Skills
Excellent Communication SkillsResearch SkillsTime ManagementAdaptabilityMulti-Tasking
Tools & Technologies
Qiclink SoftwareMicrosoft Office
Industry Keywords
Medical ClaimsInsurance Carrier LiabilityClaims Processing GuidelinesPolicy DecisionsService Guarantees
About the role
Key responsibilities & impact- Analyze medical claims to determine the extent of insurance carrier liability
- Interpret contract benefits in accordance with specific claims processing guidelines
- Examine, perform, research, and make decisions necessary to properly adjudicate claims and written inquiries
- Receive, organize, and use information regarding benefits, contract coverage, and policy decisions daily
- Coordinate daily workflow with check cycle days to meet service guarantees
- Recognize red flags for potential fraud or waste and escalate accordingly
- Investigate, track, and accurately report potential fraud or waste claims using clear and complete system notes
- Understand the broad strategic concepts of the business and link them to day-to-day claims processing functions
- Maintain external contact with providers, agents, and policyholders
- Perform other duties as assigned
Requirements
What you’ll need- A high school diploma or GED equivalent
- Minimum of 1 year proven health insurance claims adjudication experience
- Insurance background preferred
- Previous Medical/prescription claims preferred
- Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims required
- Familiarity with medical terminology, procedures and diagnosis codes preferred
- Ability to read and interpret EOB’s and claim history
- Excellent research skills
- Familiarity with Microsoft Office products
- Familiarity with Qiclink software a plus
- 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
- Ability to be punctual and dependable
Benefits
Comp & perks- Medical/Dental/Vision Insurance - 80% employer-paid
- 401(k) Retirement Plan
- Paid Holidays
- PTO
- Community Service PTO
- FSA/HSA
- Life Insurance
- Short-Term and Long-Term Disability
- Competitive compensation package
- Professional opportunities to accelerate your career
- Reasonable accommodations for qualified individuals with disabilities