Claims Adjudicator – Health Insurance

About the role

The Claims Adjudicator will evaluate health insurance claims, ensuring accurate data entry, proper coding, and compliance with plan provisions. You will work closely with internal teams and external providers to guarantee timely and correct claim processing.

Key responsibilities

• Analyze and review claims for accuracy, applying CPT and ICD‑10 coding standards.
• Process claims within established turnaround times while meeting productivity targets.
• Apply benefit schedules and plan provisions based on members' coverage selections.
• Refer complex cases to the Medical Review Department for further evaluation.
• Request additional information from agencies and healthcare providers as needed.
• Prepare and review claims reports to support coverage analysis and decision‑making.
• Provide timely internal responses to pending items and inquiries from team coordinators.

Required profile

• Advanced proficiency in English (written and verbal).
• Experience working as an adjudicator in the health insurance sector.
• Strong numerical and analytical abilities.
• High level of responsibility, organization, and proactivity.

Required skills

• Microsoft Excel.
• Microsoft Office applications.
• CPT coding.
• ICD‑10 coding.