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