Claims Adjudicator
National Healthcare Solutions Group, Inc.
Claims Adjudicator
The Claims Adjudicator is responsible for reviewing, analyzing, and processing health insurance claims in accordance with established guidelines, contractual benefits and terms, and regulatory requirements. The claims adjudicator ensures that all claims are handled accurately, efficiently, and within specified timeframes, contributing to the overall effectiveness of the claims processing team. This role requires a detailed-oriented professional with a strong ability to follow instructions and a proactive approach to identifying and resolving discrepancies.
Essential Functions
- Ensure all claims are processed in strict accordance with established guidelines and instructions.
- Review and adjudicate claims in accordance with policy benefits.
- Send claims for coverage analysis to the medical department in specific cases.
- Regularly generate and analyze claims processing reports to identify discrepancies and ensure data accuracy.
- Properly code procedures and diagnostics (CPT and ICD 10 coding)
- Verify banking information.
- Validate prescription medicines to the corresponding patient diagnosis.
- Verify expenses with the renewal date for coverage.
- Calculate expenses and deductible per policy year.
- Verify waiting periods.
- Verify pre-existing conditions and exclusions; deductible increases
- Verify dates of service.
- Verify currency conversions.
- Verify general benefits of the policy according to the contracted plan.
Minimum Qualifications
- Minimum 2 years' experience.
- Bilingual (Spanish or Portuguese).
- Experience in quality customer service.
- General knowledge and proper management of Microsoft Office
- Proactively identify discrepancies in claims; monitor claims patterns to identify opportunities for improvement.
- Ability to work under pressure.
- Ability to manage interpersonal relationships.
- Effective oral and written communication skills.
- Strong ability to follow detailed procedures and instructions with precision to ensure accurate and compliant claims adjudication.
Working Conditions
The following job-related working conditions are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential function.
Work Environment
The role primarily operates in an in-door, climate-controlled office setting working in close proximity to others. Noise level in the work environment is low to moderate. Light level provides adequate brightness for reading, computer work, and other tasks without causing glare or strain.
Physical Demands
The job primarily involves sedentary work with prolonged periods sitting at a desk. While performing the duties of this job, employees may occasionally be expected to:
- exert up to 10 pounds of force and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.
- operate standard office equipment such as copiers, computers, telephones, printers, etc.
Travel Requirements
Minimal to no travel required
Vacancy posted 20 hours ago
Similar jobs that could be interesting for youBased on the Claims Adjudicator in Miami, FL vacancy
- VIP Universal Medical Insurance Group (VUMI) is seeking a detail-oriented Claims Adjudicator to review and process health insurance claims. The ideal candidate possesses at least 2 years of experience and is bilingual in Spanish or Portuguese. Responsibilities include...ClaimsWork at office
- Alivi is searching for a Medical Claims Examiner based in Miami, Florida. This role involves providing billing and claims management... ..., particularly with Medicare. Responsibilities include adjudicating claims, resolving disputes, and maintaining accurate documentation...ClaimsWork at office
- ...and accurately applies policy conditions of coverage, processing guidelines and cost containment knowledge into the adjudication of global health claims and comprehensive cases.ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:Processes all types of global health insurance claimsConduct...ClaimsWork at office
- ...of Benefits Specialist to join a US remote team focused on resolving complex insurance billing and COI issues. You will investigate claims, communicate with patients and payers, and drive timely resolutions while maintaining HIPAA standards. The role requires EPIC...ClaimsRemote job
- ...position as a Personal Injury Case Manager/Paralegal. The position's duties include corresponding and communicating with clients, opening claims with insurance companies and requesting records from medical facilities. Applicant will need some experience in analyzing medical...Claims
Dos Santos Law Pa
Miami, FL20 days ago - A national healthcare recruiting firm is seeking a candidate with 2-3 years of experience in claims processing and billing. The role involves investigating insurance claims, verifying patient eligibility, and updating records accordingly. Strong customer service skills...Claims
$20 - $23 per hour
...office and two working remotely) Continually seek to understand and act upon client needs, concerns and priorities on various types of claims including but not limited to: Health Insurance, Worker's Compensation and Motor Vehicle Accident claims. Utilize various client...ClaimsHourly payFull timeWork at officeRemote workShift workSuncap Technology
Miami, FL5 days ago- ...experience will be considered for partnership opportunities. Lewis Brisbois is a recognized leader in the area of insurance coverage and claims. Our Insurance Coverage Practice focuses on interpreting contracts of all kinds and representing insurers in complex coverage...ClaimsWork at office
- VIP Universal Medical Insurance Group (VUMI) in Miami, Florida, seeks a Claims Team Lead to manage and support a team responsible for processing insurance claims. In this full-time role, you will ensure accurate and timely processing while fostering a collaborative environment...ClaimsFull time
- Seaboard Marine in Miami seeks a Claims Adjuster to manage a variety of insurance claims, requiring negotiation skills and ongoing relationship management. This position offers long-term employment with opportunities for growth while requiring bilingual (English and Spanish...Claims
- ...throughout Florida and the United States is looking for an attorney to join their team focused on the defense of first party property claims. This associate position will assist with all aspects of litigation, including review of claims file, drafting status reports to...ClaimsFull timeWork at office
$300k
...Attorney Medical Malpractice Defense - Miami, FL Attorney Lawyer Insurance Company Litigation Policy Development Transaction _. Insurance Claims Counsel Attorney Lawyer Insurance Carrier Medical Malpractice Physician Hospital Claims Specialist Claims Management _ . Seeking...ClaimsContract workRelocation packageAimwel
Miami, FL3 days ago- ...inquiries on past due accounts, maintains cash receipts, and refers accounts to collection agencies. Processes third-party insurance claims, requests and submits claim forms, and processes insurance requests for refunds. Makes corrections to accounts, updates patient...ClaimsFull timeWork at office
University of Miami
Miami, FL2 days ago - ...probationary period. Company Description At KKP, we have in excess of 85 years of legal experience handling property insurance claims all over the Gulf Coast states. Our practice assists insureds in all aspects of property insurance claims from inception of claim...ClaimsFull timeFor contractors
Kandell, Kandell & Petrie, P.A.
Miami, FL11 days ago - ...inbound customer calls in a professional and efficient manner Provide accurate information regarding policies, billing inquiries, claims status, and account updates Deliver empathetic and patient support while resolving customer concerns Navigate multiple...Claims
Search Solution Group
Miami, FL2 days ago - ...prescriptions electronically and ensure all information is complete and accurate. Resolve issues when they arise (e.g., rejected insurance claims). Select the appropriate medicine and measure dosages to fill prescriptions. Sort, stock, label medication and monitor...ClaimsMonday to FridayWeekend work
Nuvem, Inc
Miami, FL2 days ago - ...Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career! Job Description Claims Processing: investigate insurance claims; properly resolve by follow-up & disposition. Verify patient eligibility with secondary...ClaimsPrivate practice
- ...real property, personal property, and business losses. Collaborate with forensic experts to investigate and evaluate the viability of claims in single and multi‑party litigation. Draft pleadings, discovery requests and responses, motions, and briefs. Prepare for, attend,...ClaimsWork at office
- ...Claims Correspondence Coordinator We are seeking a Claims Correspondence Coordinator to join our team at Independent Living Systems... ...and health care billing processes. Experience with claims adjudication software. Responsibilities: Demonstrate commitment to...ClaimsWork at office
- Focus: Cost Control & Litigation Management (GL & Auto Claims) Position Summary The Risk Manager is responsible for controlling risk exposure and minimizing financial loss for a telecommunications construction company, with primary responsibility for major insurance claims...ClaimsContract workFor subcontractor
- ...Technician License (RPT). Experience in managed care pharmacy. Strong understanding of pharmacy benefit management, insurance claims processing, and healthcare regulations. Preferred Qualifications: Bachelor's degree in Health Administration, Pharmacy,...Claims
$40k - $70k
...customer accounts and update information in the database. Assist customers with policy changes and inquiries. Process insurance claims and follow up with customers on claim status. Coordinate with underwriters to ensure timely policy issuance. Qualifications:...Claims- ...a highly visible enterprise sales role focused on developing and expanding relationships throughout the insurance replacement and claims ecosystem. The successful candidate will focus heavily on building partnerships with large insurance carriers, broker networks, claims...ClaimsMonday to Friday
- ...and Revenue Cycle Management, the Revenue Cycle Specialist (RCS) is responsible for reviewing and resolving outstanding insurance claims in multiple dental offices and identifying areas of opportunity to decrease aging and boost collections for training or other recommendations...ClaimsTemporary workWork at officeRemote workFlexible hours
Guardian Dentistry Partners
Miami, FL5 days ago - ...Key responsibilities Provide front-desk support and help manage overall clinic workflow Perform medical billing and coding, claims submission, and follow-up Verify insurance and assist with revenue cycle tasks Call in prescriptions and coordinate with pharmacies...ClaimsWork at office
JOHN BANCROFT HYLTON MD PA
Miami, FL22 days ago - ...background in auto and home insurance is preferred but not required.Key Responsibilities:1. Perform audits on internal processes, claims, and transactions to ensure compliance with legal, regulatory, and company standards.2. Analyze data, reports, and workflows to identify...ClaimsWork at office
$55k - $65k
...their Direct Hire opportunity. The ideal candidate will have experience Managing Non-Standard Auto Adjusters who handle a variety of claims, preferably in the state of FL. Required Qualifications 3+ years of non-standard Auto experience 1+ years in a leadership role...ClaimsTemporary workLocal area$50k - $55k
...Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance Claims Representative, Auto PRIMARY PURPOSE OF THE ROLE: To analyze and process low to mid-level auto and transportation claims. ESSENTIAL...ClaimsContract workWork at officeLocal areaFlexible hoursSedgwick
Miami, FL2 days ago- ...Biller to join our Patient Accounts team. The Professional Biller will be responsible for the accurate and timely billing of medical claims, follow-up on unpaid accounts, resolving billing issues, and ensuring compliance with all applicable healthcare billing regulations...ClaimsFull timeWork at office
- ...Claims & Billing Analyst We are seeking a Claims & Billing Analyst to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality...Claims
Do you want to receive more vacancies?
Subscribe and receive similar vacancies to Claims Adjudicator. Be the first to apply!
