Claims Examiner

Job Description

Job Description

We are seeking a Claims Examiner 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 of life and maximizing independence for all vulnerable populations.

About the Role:

The Claims Examiner plays an essential role by thoroughly reviewing and evaluating insurance claims to ensure accuracy, compliance, and appropriateness of payments. This position involves analyzing medical documentation, policy details, and billing information to determine the validity of claims and identify any discrepancies or potential fraud. The Claims Examiner collaborates with healthcare providers, and internal teams to resolve claim issues and facilitate timely reimbursement. By maintaining up-to-date knowledge of healthcare regulations and insurance policies, the Claims Examiner helps protect the organization from financial loss and supports the delivery of fair and efficient claims processing. Ultimately, this role contributes to the integrity and sustainability of the organization by ensuring claims are processed accurately and ethically.

Minimum Qualifications:

• High school diploma or GED.
• Minimum of 2 years experience in claims examination, medical billing, or healthcare insurance processing.
• Strong understanding of medical terminology, insurance policies, and healthcare billing codes (e.g., ICD-10, CPT).
• Proficiency with claims management software and Microsoft Office suite.

Preferred Qualifications:

• Associate’s degree or Bachelor's degree in health administration, healthcare management, or a related discipline.
• Certification such as Certified Professional Coder (CPC) or Certified Claims Professional (CCP).
• Experience working within the health care and social assistance industry or with government healthcare programs.
• Familiarity with regulatory frameworks such as HIPAA and the Affordable Care Act.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Review and analyze health insurance claims for completeness, accuracy, and compliance with policy terms and regulatory requirements.
• Verify medical codes, treatment documentation, and billing information to ensure services are properly covered and billed.
• Investigate and resolve claim discrepancies by communicating with providers and internal stakeholders.
• Identify and escalate potential fraudulent claims or billing errors to compliance or legal teams.
• Maintain detailed records of claim evaluations and stay current with healthcare laws and industry standards to support audits and improve processing workflows.

• Perform other duties as assigned.