Medical Health Insurance Claims Adjuster

About Insurance Administrative Solutions

Insurance Administrative Solutions, L.L.C. (“IAS”), an Integrity company headquartered in Clearwater, Florida, is a third-party administrator providing business process outsourcing for insurance carriers. Formed in 2002, IAS administers policies for insureds residing all across the United States.

Job Summary: Analyze medical claims to determine the extent of insurance carrier liability. Interpret contract benefits in accordance with specific claims processing guidelines.

Primary Responsibilities other duties may be assigned as necessary:

• Examine/perform/research & make decisions necessary to properly adjudicate claims and written inquiries.

• Receive, organize and make daily use of information regarding benefits, contract coverage, and policy decisions.

• Interpret contract benefits in accordance with specific claim processing guidelines.

• Coordinate daily workflow to coincide with check cycle days to meet all service guarantees.

• Based on established guidelines and/or historical knowledge an adjuster will need to recognize red flags for potential fraud or waste and escalate accordingly.

• Adjusters who handle the potential fraud or waste claims will investigate, track via clear and complete system notes and accurately report on each file/case in a timely manner.

• Understand broad strategic concept of our business and link these to the day-to-day business functions of claims processing.

• Maintain external contact with providers/agents/policyholders.

Primary Skills & Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

• A high school diploma or GED equivalent

• Minimum of 1 year proven health insurance claims adjudication experience.

• Insurance background preferred; previous Medical/prescription claims preferred.

• Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims required.

• Familiarity with medical terminology, procedures and diagnosis codes preferred.

• Ability to read and interpret EOB’s claim history, and excellent research skills.

• Familiarity with Microsoft Office products; familiarity with Qiclink software a plus.

• Ability to calculate deductible and co-insurance amounts.

• Ability to adapt and respond to different types of people and tasks.

• Excellent communication and documentation skills.

• Ability to multi-task, prioritize, and manage time effectively and efficiently.

• Reliable transportation and the ability to be punctual and dependable.

Benefits Available

• We value flexibility and recognize the importance of work‑life balance. This role will begin as fully onsite to support learning and team integration. As proficiency is demonstrated, hybrid work opportunities may be introduced, dependent on business needs and department practices.

• Medical/Dental/Vision Insurance

• 401(k) Retirement Plan

• Paid Holidays

• PTO

• Community Service PTO

• FSA/HSA

• Life Insurance

• Short-Term and Long-Term Disability