Health Plans Claims Processor

Full-Time Claims Examiner I

Capital Health Plan is looking for a full-time Claims Examiner I to join our team in Tallahassee, FL. In this full-time role, you will help ensure insurance claims are reviewed, evaluated, and processed accurately according to departmental policies, provider agreements, and member benefits.

This is a full-time position working Monday through Friday from 8:00 AM to 5:00 PM. Team members must also be willing to work evenings, weekends, and overtime as directed.

High school diploma or equivalent or one to three months of related experience and/or training or an equivalent combination of education and experience

Ability to communicate effectively with customers and employees

Ability to solve problems involving a few concrete variables in standardized situations

Knowledge of, or ability to learn, medical terminology

Skilled in the use of, or ability to learn, Microsoft Outlook, Word, and Excel

Working knowledge of, or ability to learn, Adobe Acrobat software

Ability to meet and maintain state, federal, and CHP guidelines and standards for timeliness and accuracy of claims processing

Ability to read, understand, and interpret claim editing documentation and healthcare regulatory information

What can you expect as our Claims Examiner I?

As a Claims Examiner I, you will analyze insurance claims of low to moderate difficulty to determine Capital Health Plan's liability and adjudicate claims in accordance with departmental policies and provider agreements. Your day will include reviewing claims for errors or missing information, evaluating claims for payment based on provider agreements and member benefits, and issuing appropriate denial notifications when necessary. You will follow up on pending claims, work with other departments to resolve outstanding issues, maintain processing statistics, and notify the Claims Supervisor when pending claims exceed established limits. You will also perform data validation on scanned and OCR claims, enter information from paper claims, and refer questionable claims for further review. Success in this role will be measured by your ability to meet standards for production, accuracy, and customer service while progressing to more complex claims within six months.

We are a not-for-profit health care organization that has served the panhandle since 1982, delivering high-quality, affordable, and patient-centered care. Whether delivering direct care, supporting patients, or ensuring smooth operations behind the scenes, every team member plays a vital role in fulfilling our mission to improve the health of our communities. We are dedicated to fostering a professional, respectful, and inclusive workplace where employees are valued, supported in their growth, and empowered to make a meaningful impact.