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 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.

Compensation / Pay

Rate (Up to): $22.50