Medical Insurance Claims Adjuster

Job Description

Job Description

Our firm is representing a professional operations center in Clearwater that specializes in high-level policy administration. We are seeking a  Medical Claims Adjuster who brings a unique blend of medical coding knowledge and professional call center experience.

This is a 100% in office role.

This is not a generic billing role; it is a specialized position designed for a "subject matter expert" who can navigate the complexities of healthcare policies, verify coding accuracy, and provide high-level clarity to policyholders. If you have a background in a medical insurance call center and are looking for a more technical, adjudication-focused career path, this is the ideal move.

Primary Duties and Responsibilities:

• Claims Adjudication: Review medical insurance claims to determine coverage eligibility based on specific policy language and regulatory guidelines.
• Coding Verification: Utilize ICD-10 and CPT-4 coding expertise to ensure healthcare provider billings accurately match the services and diagnoses rendered.
• Billing Analysis: Scrutinize HCFA-1500 and UB-04 forms to identify billing inconsistencies, upcoding, or errors.
• Policyholder Advocacy: Act as a professional point of contact for members, explaining claim determinations and providing clear, empathetic guidance on benefits.
• Quality Assurance: Conduct rigorous audits on documentation to ensure 100% payment accuracy and strict compliance with internal standards.
• Research & Resolution: Take initiative in resolving complex billing disputes through research and collaboration with providers.

Experience and Qualifications:

• Insurance Call Center Experience: Proven experience working in a medical insurance call center or a high-volume health insurance service environment is required.
• Technical Proficiency: 1+ years of experience in Medical Coding or Billing. You must be comfortable with the "nuances" of healthcare insurance (Candidates will be tested on ICD-10/CPT-4 proficiency).
• Medicare Fluency: Previous experience specifically with Medicare or  Medicare Supplement claims is a significant advantage.
• Critical Thinking: The ability to interpret complex contract language and make informed, independent decisions regarding claim eligibility.
• Professional Presence: Exceptional verbal communication skills with the ability to remain professional in a structured, schedule-driven environment.
• Reliability: A track record of punctuality and dependability is essential for this on-site team.

Why Join This Team?

• Professional Advancement: Move beyond standard billing into a strategic claims and member-support role.
• Structured Environment: Enjoy a consistent, professional first-shift schedule with a company that values accuracy over raw volume.
• Industry Stability: Build a long-term career in a stable and essential sector of the healthcare world.

PrideStaff is a national staffing organization, delivering innovative solutions to the challenges employers face every day. Over the years, PrideStaff has been a consistent industry leader, developing technology and service processes that allow our organization to deliver superior performance. With locations across the United States, we're well positioned to partner with clients and candidates to ensure a successful match of employee talent with customer needs. When it comes to your success, we leave nothing to chance!

Our Mission: Consistently provide client experiences focused on what they value most.

Company Description

PrideStaff is a national staffing organization, delivering innovative solutions to the challenges employers face every day. Over the years, PrideStaff has been a consistent industry leader, developing technology and service processes that allow our organization to deliver superior performance. With locations across the United States, we're well positioned to partner with clients and candidates to ensure a successful match of employee talent with customer needs. When it comes to your success, we leave nothing to chance! \r\n\r\nOur Mission: Consistently provide client experiences focused on what they value most.