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Claim specialist jobs in West Little River, FL - 92 jobs
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Claim Specialist
Claim Processor
Claims Adjuster
Medical Claims Analyst
Verification Specialist
Senior Claims Specialist
Claims Adjudicator
Analyst, Healthcare Medical Coding - Disputes, Claims & Investigations
Stout
Claim specialist job in Boca Raton, FL
At Stout, we're dedicated to exceeding expectations in all we do - we call it Relentless Excellence . Both our client service and culture are second to none, stemming from our firmwide embrace of our core values: Positive and Team-Oriented, Accountable, Committed, Relationship-Focused, Super-Responsive, and being Great communicators. Sound like a place you can grow and succeed? Read on to learn more about an exciting opportunity to join our team. About Stout's Forensics and Compliance GroupStout's Forensics and Compliance group supports organizations in addressing complex compliance, investigative, and regulatory challenges. Our professionals bring strong technical capabilities and healthcare industry experience to identify fraud, waste, abuse, and operational inefficiencies, while promoting a culture of integrity and accountability. We work closely with clients, legal counsel, and internal stakeholders to support investigations, regulatory inquiries, litigation, and the implementation of sustainable compliance and revenue cycle improvements.What You'll DoAs an Analyst, you will play a hands-on role in client engagements, contributing independently while collaborating closely with senior team members. Responsibilities include: Support and execute client engagements related to healthcare billing, coding, reimbursement, and revenue cycle operations. Perform detailed forensic analyses and compliance reviews to identify potential fraud, waste, abuse, and process inefficiencies. Analyze and document EMR/EHR hospital billing workflows (e.g., Epic Resolute), including charge capture, claims processing, and reimbursement logic. Assist in audits, investigations, and litigation support engagements, including evidence gathering, issue identification, and corrective action planning. Collaborate with Stout engagement teams, client compliance functions, legal counsel, and leadership to support project objectives. Support EMR/EHR implementations and optimization initiatives, including system testing, data validation, workflow review, and post-go-live support. Prepare clear, well-structured analyses, reports, and client-ready presentations summarizing findings, risks, and recommendations. Communicate proactively with managers and project teams to ensure alignment, quality, and timely delivery. Continue developing technical, analytical, and consulting skills while building credibility with clients. Stay current on healthcare regulations, payer rules, EMR/EHR enhancements, and industry trends impacting compliance and reimbursement. Contribute to internal knowledge sharing, thought leadership, and practice development initiatives within Stout's Healthcare Consulting team. What You Bring Bachelor's degree in Healthcare Administration, Information Technology, Computer Science, Accounting, or a related field required; Master's degree preferred. Two (2)+ years of experience in healthcare revenue cycle operations, EMR/EHR implementations, compliance, or related healthcare consulting roles. Experience supporting consulting engagements, audits, or investigations related to billing, coding, reimbursement, or compliance. Epic Resolute or other hospital billing system experience preferred; Epic certification a plus. Nationally recognized coding credential (e.g., CCS, CPC, RHIA, RHIT) required. Additional certifications such as CHC, CFE, or AHFI preferred. Working knowledge of EMR/EHR system configuration, workflows, issue resolution, and optimization. Proficiency in Microsoft Office (Excel, PowerPoint, Word); experience with Visio, SharePoint, Tableau, or Power BI preferred. Understanding of key healthcare regulatory and compliance frameworks, including CMS regulations, HIPAA, and the False Claims Act. Willingness to travel up to 25%, based on client and project needs. How You'll Thrive Analytical and Detail-Oriented: You are comfortable working with complex data and systems, identifying risks, and drawing well-supported conclusions. Collaborative and Client-Focused: You communicate clearly, work well in team-based environments, and contribute to positive client relationships. Accountable and Proactive: You take ownership of your work, manage priorities effectively, and deliver high-quality results on time. Adaptable and Curious: You are eager to learn new systems, regulations, and methodologies in a fast-paced consulting environment. Growth-Oriented: You seek feedback, develop your technical and professional skills, and build toward increased responsibility. Aligned with Stout Values: You demonstrate integrity, professionalism, and a commitment to excellence in all client and team interactions. Why Stout? At Stout, we offer a comprehensive Total Rewards program with competitive compensation, benefits, and wellness options tailored to support employees at every stage of life. We foster a culture of inclusion and respect, embracing diverse perspectives and experiences to drive innovation and success. Our leadership is committed to inclusion and belonging across the organization and in the communities we serve. We invest in professional growth through ongoing training, mentorship, employee resource groups, and clear performance feedback, ensuring our employees are supported in achieving their career goals. Stout provides flexible work schedules and a discretionary time off policy to promote work-life balance and help employees lead fulfilling lives. Learn more about our benefits and commitment to your success. en/careers/benefits The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria necessary to successfully perform the job. Stout is an Equal Employment Opportunity. All qualified applicants will receive consideration for employment on the basis of valid job requirements, qualifications and merit without regard to race, color, religion, sex, national origin, disability, age, protected veteran status or any other characteristic protected by applicable local, state or federal law. Stout is required by applicable state and local laws to include a reasonable estimate of the compensation range for this role. The range for this role considers several factors including but not limited to prior work and industry experience, education level, and unique skills. The disclosed range estimate has not been adjusted for any applicable geographic differential associated with the location at which the position may be filled. It is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $60,000.00 - $130,000.00 Annual. This role is also anticipated to be eligible to participate in an annual bonus plan. Information about benefits can be found here - en/careers/benefits.$35k-43k yearly est. 3d agoPatient Claims Specialist - Bilingual Only
Modernizing Medicine
Claim specialist job in Boca Raton, FL
ModMed is hiring a driven Patient Claim Specialist who will play a pivotal role in shaping a positive patient experience within our passionate, high-performing Revenue Cycle Management team. As a critical team member, you will support patients receiving care from ModMed BOOST service providers and doctors, ensuring their account needs are met excellently. This direct interaction with our customers' patients makes you an integral part of ModMed's business. It opens the door to an exhilarating career path for individuals driven by a passion for healthcare and exceptional customer service within a fast-paced Healthcare IT company that is genuinely Modernizing Medicine! Your Role: * Serve as primary contact for all inbound and outbound patient calls regarding patient balance inquiries, claims processing, insurance updates, and payment collections * Initiate outbound calls to patients of RCM clients to understand and address any account/payment issues, such as demographic and insurance updates * Input and update patient account information and document calls into the Practice Management system * Special Projects: Other duties as required to support and enhance our customer/patient-facing activities Skills & Requirements: * High School Diploma or GED required * Availability to work 9:30-5:30pm PST or 11:30am to 8:30 pm EST * Minimum of 1-2 years of previous healthcare administration or related experience required * Basic understanding of medical billing claims submission process and working with insurance carriers required (e.g., Medicare, private HMOs, PPOs) * Manage/ field 60+ inbound calls per day * Bilingual is a requirement (Spanish & English) * Proficient knowledge of business software applications such as Excel, Word, and PowerPoint * Strong communication and interpersonal skills with an emphasis on the ability to work effectively over the telephone * Ability and openness to learn new things * Ability to work effectively within a team in order to create a positive environment * Ability to remain calm in a demanding call center environment * Professional demeanor required * Ability to effectively manage time and competing priorities #LI-SM2$78k-98k yearly est. Auto-Apply 45d agoClaims Specialist
Solis Health Plans
Claim specialist job in Miami, FL
ESSENTIAL DUTIES & RESPONSIBILITIES To perform this job, an individual must perform each essential function satisfactorily, with or without a reasonable accommodation; including, but not limited to: Serve as a liaison between the plan, claims, providers, and various departments to effectively identify and resolve claims issues. Collaborate with various business units to resolve claims issues to ensure prompt and accurate claims adjudication. Review, research, solve and process assigned work. This would include navigating multiple computer systems and platforms (e.g. Verify pricing, prior authorizations, applicable benefits) Audit check run and send claims for corrections. Ensure that the proper benefits are applied to each claim by using the appropriate tools, processes, and procedures (e.g. Claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/ certificates tool) Independently complete on a daily basis all documentation and communicate the status of claims as needed adhering to all reporting requirements. Communicate through correspondence with members and providers regarding claim payment or required information, using clear, simple language to ensure understanding. Meet and maintain the performance goals established for the position in the areas of quality, production, and attendance. Performs other duties as assigned. QUALIFICATIONS & EDUCATION High school diploma / GED (or higher) OR 5+ years of equivalent working experience. Knowledge of Medical Terminology, coding, and diagnosis coding is helpful. Excellent verbal and written communication skills. Commitment to excellence and high standards. Strong organizational, problem-solving, and analytical skills. Able to manage priorities and workflow. Demonstrates a high level of professionalism in dealing with confidential and sensitive issues. Ability to work effectively, independently and in a team environment. Ability to deal effectively with a variety of individuals. Fluency in Spanish and English required. Proficiency in computer software (i.e. Microsoft Word, Excel, Power-Point, and Outlook) and the ability to learn new and complex computer system applications (including comfort using short-cut keys/demands). WORKING CONDITIONS The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. Interacts with health plan members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances. This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. The work schedule is approximate, and hours/days may change based on company needs.$34k-62k yearly est. Auto-Apply 3d agoClaims Specialist
Quadrant Health Group
Claim specialist job in Boca Raton, FL
Job Description Join our dynamic team at Quadrant Health Group! Quadrant Billing Solutions, a proud member of the Quadrant Health Group, is seeking a passionate and dedicated Claims Specialist to join our growing team. You will play a vital role focused on ensuring that healthcare services are delivered efficiently and effectively. Why Join Quadrant Health Group? Competitive salary commensurate with experience. Comprehensive benefits package, including medical, dental, and vision insurance. Paid time off, sick time and holidays. Opportunities for professional development and growth. A supportive and collaborative work environment. A chance to make a meaningful impact on the lives of our clients. Compensation: $18 - $24 per hour - Full-time What You'll Do: The ideal candidate is organized, persistent, and results-driven, with deep knowledge of out-of-network billing for Substance Use Disorder (SUD) and Mental Health (MH) services. You'll join a high-performing team focused on maximizing collections, reducing aging A/R, and ensuring every dollar is pursued. Major Tasks, Duties and Responsibilities: Proactively follow up on unpaid and underpaid claims for Detox, Residential, PHP, and IOP levels of care. Manage 500-700 claims per week, prioritizing efficiency and accuracy. Handle 4-5 hours of phone time per day with strong communication skills. Communicate with payers via phone, portals, and written correspondence to resolve billing issues. Identify trends in denials and underpayments and escalate systemic issues. Dispute and overturn wrongly denied claims. Update and track claims using CMD (CollaborateMD) and internal task systems. Follow QBS workflows using Google Drive, Docs, Sheets, and Kipu EMR. Maintain professional and timely communication with internal teams and facility partners. Bonus Experience (Not Required): Handling refund requests and appeals. Preparing and submitting level 1-3 appeals (e.g., medical necessity, low pay, timely filing). Gathering and submitting medical records for appeal support. Working with utilization review (UR) or clinical teams. Familiarity with ASAM and MCG medical necessity criteria. Exposure to payment posting, authorization reviews, or credentialing. What You'll Bring: Minimum 1 year of SUD/MH billing and claims follow-up experience (required). High School Diploma or equivalent, associate or bachelor's degree (preferred). Strong understanding of insurance verification, EOBs, and RCM workflows. Familiarity with major payers: BCBS, Cigna, Aetna, UHC, Optum, TriWest. Experience overturning insurance denials is a strong plus. Proficient in CMD (CollaborateMD) and Kipu EMR (strongly preferred). Excellent written and verbal communication skills. Highly organized, detail-oriented, and capable of managing multiple priorities. Why Join Quadrant Billing Solutions? Rapid career growth in a mission-driven, niche billing company. Collaborate with clinical and billing experts who understand behavioral health. Join a tight-knit, supportive team culture. Gain opportunities for leadership advancement as the company scales.$18-24 hourly 18d agoSenior Claims Specialist
DPR Construction
Claim specialist job in Florida City, FL
The Senior Claims Specialist will be responsible for all aspects of complex Construction Defect and Property Damage incidents and claims for DPR (and DPR-related entities), as assigned. Reporting: Role reports to Insured Claims Manager and Insured Claims Leader Specific Duties Include: Claims & Incident Management (General): * Initial triage and processing of incidents received from project teams for DPR (and DPR-related entities). * Input and/or review all incidents reported in DPR's RMIS system. * Working with the incident triage group to ensure timely and appropriate review of all incidents * Ensure all necessary information is compiled to properly manage claims. This includes working with the DPR teams to collect relevant documents such as the Prime contract, Subcontracts, Certificates of Insurance, Owner Policy Documents, Project Documents and Project Specific Coverage information, etc. * Assess all potential risks, as well as identify all contractual risk transfer mechanisms. * Analyzing potential insurance coverage for all applicable lines of coverage and report, with all appropriate documents and information, potential claims for DPR (and DPR-related entities) to the broker for any applicable program (Traditional, CCIP, OCIP). * Assist with the development and training of other DPR Workgroups (and DPR-related entities) around CD/PD Best Practices. Construction Defect & Property Damage (CD/PD) Specific Claims Managment: * Manage all assigned claims in DPR's RMIS system relating to Construction Defect and Property Damage matters for DPR (and DPR-related entities). This would include using all appropriate lines of coverage such as Commercial General Liability, Builder's Risk, Property, Contractor's Pollution Liability and Professional Liability, whether the policies are placed by DPR or our Clients. * Act as a liaison between all parties involved, including but not limited to, carriers, clients, trade partners, brokers, consultants, attorneys and DPR project teams (and DPR-related entities), as it relates to claim progress, strategy, expenses, and settlements. * Management of and coordination with DPR's consultants and outside attorneys throughout the claim process. * Continuously analyze claim-specific details as the claim progresses to devise key strategies in conjunction with all internal stakeholders and outside consultants. * Proactive management and coordination of all phases of the DPR CD/PD Claims Workflow. Key Skills: * Basic working knowledge and familiarity of: * Commercial General Liability * Property Insurance (Including Inland Marine and Builder's Risk * Pollution Liability * Professional Liability * Controlled Insurance Programs (CCIP/OCIP) * RMIS Systems * Construction Industry Expertise * Strategic thinking * Strong written and oral communication skills * High level of EQ (Soft skills) * Self-Starter * Highly organized and responsive; ability to meet deadlines * Detail Oriented * Contractual risk assessment * Dispute management * Integrity * Ability to mentor and inspire others * Team player * Willingness to understand and advance the DPR Culture * Proactive Learner Qualifications: * A minimum of 5-7 years relevant construction industry and/or insurance industry experience. * Previous experience in construction company Risk Management highly desired. * Position location - TBD based on location of most qualified candidate. DPR Construction is a forward-thinking, self-performing general contractor specializing in technically complex and sustainable projects for the advanced technology, life sciences, healthcare, higher education and commercial markets. Founded in 1990, DPR is a great story of entrepreneurial success as a private, employee-owned company that has grown into a multi-billion-dollar family of companies with offices around the world. Working at DPR, you'll have the chance to try new things, explore unique paths and shape your future. Here, we build opportunity together-by harnessing our talents, enabling curiosity and pursuing our collective ambition to make the best ideas happen. We are proud to be recognized as a great place to work by our talented teammates and leading news organizations like U.S. News and World Report, Forbes, Fast Company and Newsweek. Explore our open opportunities at ********************$70k-89k yearly est. Auto-Apply 60d+ agoMedical Coding Appeals Analyst
Carebridge
Claim specialist job in Miami, FL
Sign On Bonus: $1,000 Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law This position is not eligible for employment based sponsorship. Ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. PRIMARY DUTIES: * Review medical record documentation in support of Evaluation and Management, CPT, HCPCS and ICD-10 code. * Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducting clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy. * Translates medical policies into reimbursement rules. * Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits. * Coordinates research and responds to system inquiries and appeals. * Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy. * Perform pre-adjudication claims reviews to ensure proper coding was used. * Prepares correspondence to providers regarding coding and fee schedule updates. * Trains customer service staff on system issues. * Works with providers contracting staff when new/modified reimbursement contracts are needed. Minimum Requirements: Requires a BA/BS degree and a minimum of 2 years related experience; or any combination of education and experience, which would provide an equivalent background. Certified Professional Coder (CPC) or Registered Health Information Administrator (RHIA) certification required. Preferred Skills, Capabilities and Experience: * CEMC, RHIT, CCS, CCS-P certifications preferred. Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.$48k-74k yearly est. Auto-Apply 60d+ agoClaims Examiner III
Doctors Healthcare Plans, Inc.
Claim specialist job in Miami, FL
Job Description The Claims Examiner III ensures that claims are processed according to department standards and assists the Claims manager in maintaining the workflow and processes, in order to achieve set goals. Key Responsibilities: Review and release professional and institutional claims Process Member Reimbursement claims Coordinates with the Assistant Director the weekly/monthly workflow issues and set goals for the department Assists the Assistant Director on generating reports to track productivity and pending items Collaborate in the application of policies and procedures of the department Collaborate with the Assistant Director to ensure the team is meeting production and quality metrics Communicate effectible to the department staff the strategy to improve performance and meet stablished goals Maintain a positive environment that support staff well-being and foster an atmosphere that builds teamwork Ensure that the team utilizes the system capabilities to its maximum potential Performs other duties as necessary Qualifications: High School Diploma or GED 3+ years as Medical Claims Examiner Experience in contract interpretation Knowledge of CMS guidelines and regulations Ability to work Windows and other computer applications Ability to work well with others Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member. No Third Party Agencies or Submissions Will Be Accepted. Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein. Powered by JazzHR q5FAGx79Ms$29k-47k yearly est. 13d agoClaims Examiner
Heritage Mga LLC
Claim specialist job in Sunrise, FL
THIS ROLE IS FOR: 1571 Sawgrass Parkway, Sunrise FL The Role is 100% ON SITE Investigates, evaluates, reserves, negotiates and settles assigned claims in accordance with Best Practices. Provides quality claim handling and superior customer service on assigned claims, while engaging in indemnity and expense management. Promptly manages claims by completing essential functions including contacts, investigation, damages development, evaluation, reserving, and disposition. Responsibilities: Provides voice to voice contact within 24 hours of first report. Conducts timely coverage analysis and communication with insured based on application of policy information, facts or allegations of each case. Consults with Unit Manager on use of Claim Coverage Counsel. Investigates each claim through prompt contact with appropriate parties such as policyholders, claimants, law enforcement agencies, witnesses, agents, medical providers and technical experts to determine the extent of liability, damages, and contribution potential. Records necessary statements. Identifies resources for specific activities required to properly investigate claims such as Subro, Fire or Fraud investigators and to other experts. Requests through Unit Manager and coordinates the results of their efforts and findings. Verifies the nature and extent of injury or property damage by obtaining and reviewing appropriate records and damages documentation. Maintains effective diary management system to ensure that all claims are handled timely. Evaluates liability and damages exposure, and establishes proper indemnity and expense reserves, at required time intervals. Utilizes evaluation documentation tools in accordance with department guidelines. Responsible for prompt, cost effective, and proper disposition of all claims within delegated authority. Negotiate disposition of claims with insured's and claimants or their legal representatives. Recognizes and implements alternate means of resolution. Maintains and document claim file activities in accordance with established procedures. Attends depositions and mediations and all other legal proceedings, as needed. Protects organization's value by keeping information confidential. Maintains compliance with Claim Department's Best Practices. Provides quality customer service and ensures file quality Supports workload surges and/or Catastrophe operations as needed to include working significant overtime during designated CATs. Communicates with co-workers, management, clients, vendors, and others in a courteous and professional manner. Participates in special projects as assigned. Some overnight travel maybe required. Maintains the integrity of the company and products offered by complying with federal and state regulations as well as company policies and procedures. Qualifications: Associate's Degree required; Bachelor's Degree preferred. A combination of education and significant directly related experience may be considered in lieu of degree. 620 Licensure required. One to three years of experience processing claims; property and casualty segment preferred. Experience with Xactware products preferred. Demonstrated ability to research, conduct proactive investigations and negotiate successful resolutions. Proficiency with Microsoft Office products required; internet research tools preferred. Demonstrated customer service focus / superior customer service skills. Excellent communication skills and ability to interact on a professional level with internal and external personnel Results driven with strong problem solving and analytical skills. Ability to work independently in a fast paced environment; meets deadlines, and manages changing priorities effectively. Detail-oriented and exceptionally organized Collaborative partner; ability to contribute to a positive work environment. General Information: All employees must pass a pre-employment background check. Other checks may be needed based on position: driving history, credit report, etc. The preceding has been designed to indicate the general nature of work performed; the level of knowledge and skills typically required; and usual working conditions of this position. It is not designed to contain, or be interpreted as, a comprehensive listing of all requirements or responsibilities that may be required by employees in this job. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time. Heritage Insurance Holdings, Inc. is an Equal Opportunity Employer. We will not discriminate unlawfully against qualified applicants or employees with respect to any term or condition of employment based on race, color, national origin, ancestry, sex, sexual orientation, age, religion, physical or mental disability, marital status, place of birth, military service status, or other basis protected by law.$29k-47k yearly est. Auto-Apply 60d+ agoClaims Examiner
Independent Living Systems
Claim specialist job in Miami, FL
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 a critical role in the health care and social assistance industry 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 Examiner collaborates with healthcare providers, insurance agents, and internal teams to resolve claim issues and facilitate timely reimbursement. By maintaining up-to-date knowledge of healthcare regulations and insurance policies, the 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 healthcare insurance system 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: 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, members, and internal departments. 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.$29k-39k yearly est. Auto-Apply 43d agoMedical Coding Appeals Analyst
Elevance Health
Claim specialist job in Miami, FL
Sign On Bonus: $1,000 **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. **Alternate locations may be considered if candidates reside within a commuting distance from an office.** Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. This position is not eligible for employment based sponsorship. **Ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria.** PRIMARY DUTIES: + Review medical record documentation in support of Evaluation and Management, CPT, HCPCS and ICD-10 code. + Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducting clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy. + Translates medical policies into reimbursement rules. + Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits. + Coordinates research and responds to system inquiries and appeals. + Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy. + Perform pre-adjudication claims reviews to ensure proper coding was used. + Prepares correspondence to providers regarding coding and fee schedule updates. + Trains customer service staff on system issues. + Works with providers contracting staff when new/modified reimbursement contracts are needed. **Minimum Requirements:** Requires a BA/BS degree and a minimum of 2 years related experience; or any combination of education and experience, which would provide an equivalent background. Certified Professional Coder (CPC) or Registered Health Information Administrator (RHIA) certification required. **Preferred Skills, Capabilities and Experience:** + CEMC, RHIT, CCS, CCS-P certifications preferred. Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.$38k-62k yearly est. 7d agoClaims Processor
The Law Offices of Kanner and Pintaluga
Claim specialist job in Boca Raton, FL
Founded in 2003, Kanner & Pintaluga is a NLJ500 and Mid-Market Pro 50 law firm that has recovered over $1 billion for property damage and personal injury clients nationwide. With nearly 100 lawyers and more than 30 offices throughout the Central and Southeastern United States, our primary goal is to achieve the most favorable outcome for our clients, who have the absolute right to receive the maximum compensation for their damages. POSITION SUMMARY: The Claims Processor is responsible for handling insurance claims, obtaining and verifying information, corresponding with insurance agents and beneficiaries, and promptly sending Letters of Representation for the case to begin its process. ESSENTIAL JOB FUNCTIONS: Open claims with insurance companies. Handle incoming and outgoing calls as well as faxes. Perform general data entry tasks. Verify the information for accuracy. Perform other related duties as assigned. EXPERIENCE/REQUIREMENTS: Full-time, 8:00 am to 5:00 pm, M-F. High school/GED diploma required. Strong customer service skills and experience. Proficient with Microsoft Office programs (Word, Excel, and Outlook). Ability to manage a heavy workload in a fast-paced environment. Ability to communicate with clients and co-workers effectively and efficiently. Possess excellent organizational skills and the ability to multitask and prioritize workload. FIRM BENEFITS The Firm offers a competitive benefits package for our full-time employees and their families. Here is a summary of our benefits (the list is not all-inclusive): Competitive Wage Paid Time Off, Holiday, Bereavement, and Sick Time 401K Retirement Savings Plan with Firm match Group Medical/Dental/Vision Plans Employer-Covered Supplemental Benefits Voluntary Supplemental Benefits Annual Performance Reviews Equal Opportunity Statement Kanner & Pintaluga is an Equal Opportunity Employer. Kanner & Pintaluga retains the right to change, assign, or reassign duties and responsibilities to this position at any time - in its sole discretion. Employment is at will. E-Verify This employer participates in E-Verify and will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S. If E-Verify cannot confirm that you are authorized to work, this employer is required to give you written instructions and an opportunity to contact Department of Homeland Security (DHS) or Social Security Administration (SSA) so you can begin to resolve the issue before the employer can take any action against you, including terminating your employment. Employers can only use E-Verify once you have accepted a job offer and completed the I-9 Form.$29k-47k yearly est. Auto-Apply 11d agoClaims Adjudicator
Best Doctors Insurance Services
Claim specialist job in Miami, FL
Effectively 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 claims Conduct claims analysis reviewing in detail claim documentation, medical reports and supporting documentation to decide compensability Examine with accuracy policy and member information, plan conditions of coverage and processing guidelines against claim documentation to determine benefit application Conduct post claim underwriting reviews to identify possible pre-existing condition Utilize anti-fraud policies to mitigate fraud possibility for submitted claims Review benefit letter / medical authorizations for cost and benefit application Evaluate claim compensability based on procedures performed, treatment intensity and diagnosis Validate benefit accumulators, patient responsibility, duplicate claim prevention and provider discount Assign ICD-10 codes along with valid procedure codes when necessary Apply Usual, Customary and Reasonable pricing guidelines to determine acceptable claim cost Maintain acceptable productivity and turnaround times for all assignments Maintain high work accuracy and quality scores Support team with versatile assignments related to department needs Qualifications DESIRED MINIMUM QUALIFICATIONS: Proficiency in Microsoft product suite (i.e. Microsoft Office, Word, Excel, etc.) Strong analytical, problem solving and negotiating skills Ability to adapt quickly in fast paced environment Detail oriented with exceptional organizational and communication skills Complete Fluency in English, Spanish (Portuguese a plus) Proven ability to work independently and meet determined deadlines Ability to navigate and enter data utilizing multiple systems and screens Education and Experience: Associates Degree or commensurate work experience Billing/Coding Certification preferred Minimum of 3 years experience in Health Insurance Industry$33k-53k yearly est. 12d agoLevel 1 Claims Adjuster
Amwins
Claim specialist job in Sunrise, FL
Job DescriptionAmwins Specialty Auto is seeking career-oriented candidates to join a claims team within our rapidly growing company. As a Level I Claims Adjuster, you will investigate straightforward 1st party and non-injury related liability claims in accordance with company procedures.In the fast-paced environment of auto claims this role requires strong oral, written, analytical, decision making and organizational skills and lends itself to considerable career growth potential. Along with competitive salary, Amwins Specialty Auto offers a full range of benefits including insurance, retirement, and educational reimbursement programs. Amwins Specialty Auto is part of Amwins Group, the largest specialty broker in the United States, with over $14 billion of premium. This is an in office position based out of our Sunrise, FL location! Responsibilities: Establish timely contact with all applicable parties to a claim (insureds, drivers, witnesses, etc), gathers facts of the loss and clearly explains the claims process Assess coverage, identifying and addressing potential coverage issues Determine liability and document the claim file with details of the claim investigation Communicate to applicable parties the rationale behind coverage or liability decisions Document information obtained regarding damages and resolve within assigned authority limits Manage the assignment of claims to material damage handling units for inspection or repairs Maintain file notes and correspondence while performing multiple tasks associated with a fast-paced environment Manage reserve adequacy throughout the life of the claim Alert claims supervisor in the event of potential fraud, recovery, or severity escalation in the claim Ensure timely and cost-effective claim resolution Qualifications: 1-3 years of P&C adjusting experience Must be fluent in English, fluent in Spanish is preferred Associates degree or above preferred Must obtain Florida adjuster license prior to start date Ability to multi-task in a fast-paced environment Strong communication skills and ability to clearly document and communicate the basis for decisions made Excellent written skills that demonstrate clear, professional and succinct communications for file documentation, internal communications and external correspondence Strong organizational and time-management skills Courteous and professional telephone communications Ability to work in a team environment and maintain calm demeanor even during heated circumstances Benefits: Amwins Specialty Auto seeks to attract career-oriented individuals, and as such provides competitive pay and considerable opportunity for merit-based advancement. Our comprehensive benefits package includes the following: Medical, dental & vision coverage 401K with Company match Paid time-off Pay-for-Performance Flexible spending accounts Tuition reimbursement Work/Life resources Employee and Dependent life insurance Disability insurance Accidental death and dismemberment insurance No direct inquiries, please.$44k-52k yearly est. 7d agoIndependent Insurance Claims Adjuster in Fort Lauderdale, Florida
Milehigh Adjusters Houston
Claim specialist job in Fort Lauderdale, FL
IS IT TIME FOR A CAREER CHANGE? INDEPENDENT INSURANCE CLAIMS ADJUSTERS NEEDED NOW! Are you ready to embark on a dynamic and in-demand career as an Independent Insurance Claims Adjuster? This is your chance to join a thriving industry with endless opportunities for growth and advancement. Why This Opportunity Matters: With the current surge in storm-related events sweeping across the nation, there's an urgent need for new adjusters to meet the escalating demand. As a Licensed Claims Adjuster, you'll play a crucial role in helping individuals and businesses recover from unforeseen disasters and rebuild their lives. This is not just a job-it's a rewarding career path where you can make a real difference in people's lives while enjoying flexibility, autonomy, and competitive compensation. Join Our Team: Are you actively working as a Licensed Claims Adjuster with 100 claims or more under your belt? If so, that's great! If not, no problem! Let us help you on your career path as a Licensed Claims Adjuster. You're welcome to sign up on our jobs roster if you meet our guidelines. How We Can Help You Succeed: At MileHigh Adjusters Houston, we offer comprehensive training programs tailored to equip you with the essential skills and knowledge needed to excel in the field of claims adjusting. Our expert instructor, with years of industry experience, will provide you with hands-on training, insider tips, and practical insights to prepare you for real-world challenges. Whether you're a seasoned professional or a newcomer to the field, our training programs are designed to meet you where you are and help you reach your full potential as a claims adjuster. Don't miss out on this opportunity-let us assist you in advancing your career in claims adjusting and achieving your professional goals. With our guidance and support, you'll have the opportunity to thrive in a dynamic and rewarding industry, making a positive impact on the lives of others while achieving your professional goals. Seize the Opportunity Today! Contact us now at ************ or [email protected] to learn more about our training programs and take the first step towards a fulfilling career as a Licensed Claims Adjuster. Visit our website at ******************************** to explore our offerings and view our 375+ Five-Star Google Reviews. You can also find us on YouTube at: (********************************************************* and Facebook at: (************************************************** for additional resources and updates. APPLY HERE #AdjustersNeeded #CareerOpportunity #ClaimsAdjusterTraining #MileHighAdjustersHouston By applying to this position, you consent to receive informational and promotional messages from MileHigh Adjusters Houston about training opportunities and related career programs. You may opt out at any time.$43k-53k yearly est. Auto-Apply 60d+ agoClaims Adjuster (Bodily Injury)
Arc Group
Claim specialist job in Oakland Park, FL
Job Description CLAIMS ADJUSTOR (remote - East Coast) ARC Group seeks a Bodily Injury Claims Adjuster to work in a remote hybrid role for our direct client based in FL. The Claims Adjustor will investigate, evaluate, and negotiate bodily injury claims, ensuring compliance with legal standards and company policies while also coordinating with counsel on the defense of claims. There is a preference for someone in FL but Claims Adjusters from surrounding gulf and eastern seaboard states will be considered. The Claims Adjustor must have experience with bodily injury, liability, and preferably with liability, property damage, and commercial auto. But bodily injury is required. Our client is a leading insurance underwriter, and this is a great opportunity for a Claims Adjustor to join a well-established firm (45+ years) that is on a multi-year growth plan. You would join a company that offers competitive salary and comprehensive benefits package including PTO, Paid Holidays, health, vision, detail, Life & Voluntary/ADD, STD & LTD, 401K contributions and business casual dress Claims Adjustor Responsibilities: Correspond and interview with agents, witnesses, or claimants to compile information Take accurate and detailed statements from all involved parties Calculate and approve payment of claims within a certain monetary limit Negotiate and settle property losses with little oversight Coordinate with legal counsel in handling cases correctly Negotiation and Settlement: Negotiate settlements with claimants, attorneys, and other involved parties in a fair and cost-effective manner. Collaborate with internal teams, such as underwriters and claims specialists, to facilitate efficient claims resolution. Documentation and Reporting: Prepare detailed and accurate documentation of claim investigations, legal actions, and settlement agreements. Provide regular reports to management on claim status, legal developments, and financial implications. Compliance and Best Practices: Ensure compliance with state and federal regulations, as well as company policies and procedures. Stay informed about changes in legislation and industry trends affecting commercial auto insurance. Claims Adjustor Qualifications: 3+ years of previous bodily injury insurance experience, investigations or other related fields with liability, and property damage, and commercial auto (preferred) Experience in conflict resolution Strong negotiation skills Excellent written and verbal communication skills Deadline and detail-oriented Would you like to know more about our new opportunity? You can apply online while viewing all open jobs at ******************* ARC Group is a Forbes-ranked a top 20 recruiting and executive search firm working with clients nationwide to recruit the highest quality technical resources. We have achieved this by understanding both our candidate's and client's needs and goals and serving both with integrity and a shared desire to succeed. We are proud to be an equal opportunity workplace dedicated to pursuing and hiring a diverse workforce. We are a no-fee agency for candidates.$43k-53k yearly est. 4d agoPIP Claims Adjuster (On-site)
Policy Services Company LLC
Claim specialist job in Coral Springs, FL
Job DescriptionDescription: The ideal candidate is an experienced, all-lines adjuster, with at least one year of PIP handling experience for Florida PIP claims, specifically with experience clearing coverage and qualifying claimants for benefits under the policy. The candidate has a strong background in insurance claims processing, excellent communication skills, and the ability to handle complex situations with empathy and professionalism. Adjusters are responsible for assigned files within their department matched to their expertise in claims handling. They must follow protocols set forth by department supervisors/managers and operate within their stated authority and handle claims in accordance with the Florida adjuster code of ethics. Essential Duties and Functions The essential functions include, but are not limited to the following: · Evaluate auto insurance claims promptly and accurately to determine coverage, liability, and settlement options. · Conduct thorough investigations into the circumstances surrounding each claim, including obtaining statements, collecting evidence, and analyzing policy provisions. · Maintain detailed and organized claim files, documenting all relevant information, correspondence, and decisions made throughout the claims process. · Communicate effectively with policyholders, claimants, witnesses, and other involved parties to gather information, explain coverage, and provide updates on claim status. · Negotiate settlements within authorized limits, considering factors such as liability, damages, and policy coverage. · Provide exceptional customer service to policyholders and claimants, addressing inquiries, concerns, and complaints in a timely and professional manner. · Ensure compliance with insurance regulations, company policies, and industry standards in all aspects of claims handling. · Collaborate with internal teams, including underwriters, legal counsel, and other claims professionals, to resolve complex claims and mitigate risk effectively. · Identify opportunities for process improvement and contribute to the development of best practices within the claims department. · Perform quality reviews of claim files to ensure accuracy, consistency, and adherence to company guidelines. · Ensure timecards are reviewed daily for accurate hours worked. Requirements: Minimum Qualifications (Knowledge, Skills, and Responsibilities) · Strong knowledge of insurance principles, regulations, and industry standards. · Excellent analytical skills with the ability to assess liability and evaluate damages. · Exceptional communication and interpersonal skills, both written and verbal. · Proficiency in insurance claims software, preferably Microsoft Office suite. · Demonstrated ability to manage multiple priorities and meet deadlines in a fast-paced environment. · Commitment to providing outstanding customer service and maintaining professionalism in challenging situations. Required Education and Experience: · High School Diploma or equivalent experience in auto claims insurance, business administration, or a related field; Bachelor's or Associates degree preferred. · Minimum of 1+ years of PIP handling experience for Florida PIP claims · Florida Adjuster License.$43k-53k yearly est. 30d agoVerification Specialist
Get Me Healthcare
Claim specialist job in Deerfield Beach, FL
Job Description Get Me Healthcare is searching for a full-time Verification Specialist to join our team in Deerfield, FL. In this role, you'll ensure every health insurance policy is accurate, compliant, and ready to make a difference in someone's life. If you're detail-oriented, a great communicator, and thrive in a fast-paced environment, we want you on our team. Apply today and let's make things happen together! GREAT PAY As our Verification Specialist, you'll earn $17-$23 per hour, based on experience. EXCELLENT BENEFITS Health Dental Vision Life insurance PTO Catered meals in office YOUR NEW ROLE AS OUR VERIFICATION SPECIALIST This is a full-time, in-office position with a Monday through Friday work schedule. Extended hours and occasional weekend availability may be available during peak enrollment periods. As our Verification Specialist, you'll be the last set of eyes before a health insurance application is submitted. You'll review applications for accuracy, listen to live and recorded calls to ensure compliance, and work directly with agents to fix any issues in real time. Your work will ensure every policy is clean, compliant, and ready to go. REQUIREMENTS Exceptional attention to detail Strong communication skills for real-time collaboration Highly organized with the ability to multitask Team-oriented and coachable Comfortable in a fast-paced, high-accountability environment Experience in compliance, insurance processing, customer service, or admin roles is preferred, but not required. If this sounds like you, apply today to join our team! ABOUT US It all started in Boca. Our flagship Florida office is where GetMeHealthcare's winning culture was born-and it still sets the pace. This team drives results, levels up fast, and turns high potential into real performance. From sales to ops, you'll get elite training, nonstop support, and a team that's locked in on success. We grind hard, win big, and celebrate like we mean it. The office? Built for speed and collaboration. The vibe? All gas, no brakes. Bonus: on-site gym, personal trainer, and a crew that pushes each other to be great-in and out of the office. If you're hungry, competitive, and chasing something bigger, Boca is where it begins. Ready to put your skills to work in a role that truly matters? Apply now! Our initial application process is quick, easy, and mobile-friendly. Job Posted by ApplicantPro$17-23 hourly 17d agoPatient Claims Specialist - Bilingual Only
Modmed
Claim specialist job in Boca Raton, FL
We are united in our mission to make a positive impact on healthcare. Join Us! South Florida Business Journal, Best Places to Work 2024 Inc. 5000 Fastest-Growing Private Companies in America 2024 2024 Black Book Awards, ranked #1 EHR in 11 Specialties 2024 Spring Digital Health Awards, “Web-based Digital Health” category for EMA Health Records (Gold) 2024 Stevie American Business Award (Silver), New Product and Service: Health Technology Solution (Klara) Who we are: We Are Modernizing Medicine (WAMM)! We're a team of bright, passionate, and positive problem-solvers on a mission to place doctors and patients at the center of care through an intelligent, specialty-specific cloud platform. Our vision is a world where the software we build increases medical practice success and improves patient outcomes. Founded in 2010 by Daniel Cane and Dr. Michael Sherling, we have grown to over 3400 combined direct and contingent team members serving eleven specialties, and we are just getting started! ModMed's global headquarters is based in Boca Raton, FL, with a growing office in Hyderabad, India, and a robust remote workforce across the US, Chile, and Germany. ModMed is hiring a driven Patient Claim Specialist who will play a pivotal role in shaping a positive patient experience within our passionate, high-performing Revenue Cycle Management team. As a critical team member, you will support patients receiving care from ModMed BOOST service providers and doctors, ensuring their account needs are met excellently. This direct interaction with our customers' patients makes you an integral part of ModMed's business. It opens the door to an exhilarating career path for individuals driven by a passion for healthcare and exceptional customer service within a fast-paced Healthcare IT company that is genuinely Modernizing Medicine! Your Role: Serve as primary contact for all inbound and outbound patient calls regarding patient balance inquiries, claims processing, insurance updates, and payment collections Initiate outbound calls to patients of RCM clients to understand and address any account/payment issues, such as demographic and insurance updates Input and update patient account information and document calls into the Practice Management system Special Projects: Other duties as required to support and enhance our customer/patient-facing activities Skills & Requirements: High School Diploma or GED required Availability to work 9:30-5:30pm PST or 11:30am to 8:30 pm EST Minimum of 1-2 years of previous healthcare administration or related experience required Basic understanding of medical billing claims submission process and working with insurance carriers required (e.g., Medicare, private HMOs, PPOs) Manage/ field 60+ inbound calls per day Bilingual required (Spanish & English) Proficient knowledge of business software applications such as Excel, Word, and PowerPoint Strong communication and interpersonal skills with an emphasis on the ability to work effectively over the telephone Ability and openness to learn new things Ability to work effectively within a team in order to create a positive environment Ability to remain calm in a demanding call center environment Professional demeanor required Ability to effectively manage time and competing priorities #LI-SM2 ModMed Benefits Highlight: At ModMed, we believe it's important to offer a competitive benefits package designed to meet the diverse needs of our growing workforce. Eligible Modernizers can enroll in a wide range of benefits: India Meals & Snacks: Enjoy complimentary office lunches & dinners on select days and healthy snacks delivered to your desk, Insurance Coverage: Comprehensive health, accidental, and life insurance plans, including coverage for family members, all at no cost to employees, Allowances: Annual wellness allowance to support your well-being and productivity, Earned, casual, and sick leaves to maintain a healthy work-life balance, Bereavement leave for difficult times and extended medical leave options, Paid parental leaves, including maternity, paternity, adoption, surrogacy, and abortion leave, Celebration leave to make your special day even more memorable, and company-paid holidays to recharge and unwind. United States Comprehensive medical, dental, and vision benefits 401(k): ModMed provides a matching contribution each payday of 50% of your contribution deferred on up to 6% of your compensation. After one year of employment with ModMed, 100% of any matching contribution you receive is yours to keep. Generous Paid Time Off and Paid Parental Leave programs, Company paid Life and Disability benefits, Flexible Spending Account, and Employee Assistance Programs, Company-sponsored Business Resource & Special Interest Groups that provide engaged and supportive communities within ModMed, Professional development opportunities, including tuition reimbursement programs and unlimited access to LinkedIn Learning, Global presence and in-person collaboration opportunities; dog-friendly HQ (US), Hybrid office-based roles and remote availability for some roles, Weekly catered breakfast and lunch, treadmill workstations, Zen, and wellness rooms within our BRIC headquarters. PHISHING SCAM WARNING: ModMed is among several companies recently made aware of a phishing scam involving imposters posing as hiring managers recruiting via email, text and social media. The imposters are creating misleading email accounts, conducting remote "interviews," and making fake job offers in order to collect personal and financial information from unsuspecting individuals. Please be aware that no job offers will be made from ModMed without a formal interview process, and valid communications from our hiring team will come from our employees with a ModMed email address (*************************). Please check senders' email addresses carefully. Additionally, ModMed will not ask you to purchase equipment or supplies as part of your onboarding process. If you are receiving communications as described above, please report them to the FTC website.$78k-98k yearly est. Auto-Apply 44d agoClaims Examiner III
Doctors Healthcare Plans
Claim specialist job in Coral Gables, FL
The Claims Examiner III ensures that claims are processed according to department standards and assists the Claims manager in maintaining the workflow and processes, in order to achieve set goals. Key Responsibilities: Review and release professional and institutional claims Process Member Reimbursement claims Coordinates with the Assistant Director the weekly/monthly workflow issues and set goals for the department Assists the Assistant Director on generating reports to track productivity and pending items Collaborate in the application of policies and procedures of the department Collaborate with the Assistant Director to ensure the team is meeting production and quality metrics Communicate effectible to the department staff the strategy to improve performance and meet stablished goals Maintain a positive environment that support staff well-being and foster an atmosphere that builds teamwork Ensure that the team utilizes the system capabilities to its maximum potential Performs other duties as necessary Qualifications: High School Diploma or GED 3+ years as Medical Claims Examiner Experience in contract interpretation Knowledge of CMS guidelines and regulations Ability to work Windows and other computer applications Ability to work well with others Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member. No Third Party Agencies or Submissions Will Be Accepted. Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.$29k-47k yearly est. Auto-Apply 12d agoClaims Examiner
Independent Living Systems
Claim specialist job in Miami, FL
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 a critical role in the health care and social assistance industry 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 Examiner collaborates with healthcare providers, insurance agents, and internal teams to resolve claim issues and facilitate timely reimbursement. By maintaining up-to-date knowledge of healthcare regulations and insurance policies, the 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 healthcare insurance system 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: 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, members, and internal departments. 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.$29k-39k yearly est. 15d ago
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Learn more about claim specialist jobs
How much does a claim specialist earn in West Little River, FL?
The average claim specialist in West Little River, FL earns between $26,000 and $80,000 annually. This compares to the national average claim specialist range of $27,000 to $67,000.
Average claim specialist salary in West Little River, FL
$46,000
What are the biggest employers of Claim Specialists in West Little River, FL?
The biggest employers of Claim Specialists in West Little River, FL are:
- Solis Health Plans
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