Claims Adjudicator II

About Our Client

The organization serves more than 200,000 workers and their families in the hospitality and gaming industry nationwide. It focuses on developing impactful health programs and benefits that encourage participants to take an active role in managing their health and healthcare.

About the Opportunity

The Claims Adjudicator II is responsible for processing and adjudicating medical, disability, vision, and dental claims. This role ensures claims are accurately reviewed for eligibility, benefit coverage, and compliance with plan requirements while meeting established productivity and quality standards.

Responsibilities

• Screen claims for completeness and required information.
• Verify participant and dependent eligibility.
• Interpret plan benefits using Summary Plan Descriptions and other plan documents.
• Apply appropriate codes and determine payment liability.
• Evaluate submitted information for accuracy, benefit requirements, and appropriateness of care.
• Request additional information or documentation when necessary.
• Manage Medicare Secondary Payer (MSP) files.
• Process Personal Injury Protection (PIP) claims.
• Request overpayment refunds and maintain related documentation.
• Respond to verbal and written inquiries from internal and external customers.
• Process Short-Term Disability claims.
• Adjudicate claims accurately while meeting established productivity and quality goals.
• Achieve individual performance targets that support departmental metrics.

Requirements

• 3–5 years of direct experience in medical claims adjudication.
• Strong knowledge of benefit plan interpretation, including limitations, exclusions, and benefit schedules.
• Experience with eligibility verification, medical coding, coordination of benefits, and subrogation.
• Familiarity with medical terminology, ICD-10, and CPT codes.
• Preferred fluency in Spanish, both spoken and written.

Pay

Hourly wage range: $20.36–$24.97, with actual compensation based on experience, qualifications, and other relevant factors.

Benefits

• Medical insurance.
• Dental insurance.
• Vision insurance.
• Paid time off (PTO).
• Paid holidays.
• 401(k) retirement plan.
• Pension plan.
• Short- and long-term disability insurance.
• Life and AD&D insurance.
• Flexible Spending Accounts for healthcare and dependent care.
• Commuter transit benefits.
• Tuition assistance.
• Employee Assistance Program (EAP).