Claims Examiner / Claims Adjudicator

🌍 Remote, USA 🚀 Full-time 🕐 Posted Recently

Job Description

Job Title: Claims Adjudicator (Claims Examiner)

Location: Tampa Bay, FL

Schedule: Full-Time

Payrate-$19/hr.

Training: 8 weeks onsite (Full-time remote flexibility available after successful completion of training)

Position Overview

We are seeking a detail-oriented and experienced Claims Adjudicator with strong end-to-end claims processing expertise. The ideal candidate will have hands-on experience managing the full claims lifecycle—from intake and review to final resolution and adjustments. This role requires strong analytical skills, accuracy, and the ability to work independently after training.

This is a stable, full-time opportunity offering consistent hours and long-term job security, with the flexibility to transition to remote work after the initial onsite training period.

Claims Adjudication: Review, verify, and process medical claims from start to finish in accordance with company policies and benefit guidelines.
Full Claims Lifecycle Management: Handle claims from initial intake through adjudication, payment determination, and final resolution.
Documentation Review: Analyze claim forms, medical records, benefit summaries, and supporting documentation to determine eligibility and accuracy.
Coding Validation: Interpret and apply ICD-9, ICD-10, CPT, HCPCS, Revenue Codes, and applicable modifiers.
Adjustments & Rework: Process rework, reconsiderations, appeals, and claim adjustments as required.
Discrepancy Resolution: Investigate and resolve claim issues, denials, and provider disputes.
Communication: Interact professionally with providers, members, and internal teams to obtain missing information and resolve concerns.
Data Entry & System Updates: Accurately enter claim details into the claims system and maintain thorough documentation.

High School Diploma or GED (verification required)
Proven hands-on experience with end-to-end medical claims adjudication
Experience processing claims in FirstPass, NewDay, or similar claims platforms
Strong understanding of:
CPT, HCPCS, Revenue Codes, and modifiers
Copay, coinsurance, deductible, and out-of-pocket calculations
Medicare and Medicaid eligibility and claims processing
Experience handling rework, adjustments, reconsiderations, and appeals
Proficiency in Microsoft Outlook, Word, and Excel
Strong attention to detail and ability to meet productivity and quality standards
Excellent written and verbal communication skills