Virtual Insurance Claims Adjuster

The James Allen Companies Inc Published: October 9, 2017
Job Type


Job Description

Job Title: Virtual Insurance Claims Adjuster

Department: Claims Department FLSA Status: Exempt Job Status: FT

Reports To: Claims Supervisor and Manager Positions Supervised: None

Work Schedule: Flexible during core business hours, varies depending upon clients’ needs and claims volume.

Assessments: PI, Wonderlic and Claims Survey.


Use independent judgment and discretion to review, analyze, and make determinations regarding payment, partial payment, or denial of medical, vision, and dental claims, based upon specific knowledge and application of each client’s customized plan(s) using the RIMS/QicLink systems.


  • Process a minimum of 1,000 medical, dental, and vision claims per week, or an otherwise predetermined set, while achieving and maintaining a minimum of 98.5% quality accuracy.
  • Read, analyze, understand, and ensure compliance with clients’ customized plans. (A plan may be hundreds of pages or more.)
  • Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
  • Request, review and analyze any physician notes, hospital records or police reports.
  • Interview claimants, physicians, hospitals and other third parties for additional information.
  • Consult with other professionals such as attorneys, nurses, physicians and auditors who can offer additional evaluation of a claim.
  • Independently review, analyze, and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physicians and hospitals; and 3) fraud.
  • Process claims in the QicLink System.
  • Review, analyze and add applicable notes to the QicLink System.
  • Document all information gathered in available systems as needed, including the QicLink System
  • Review billed procedure and diagnosis codes on claims for billing irregularities.
  • Analyze claims for billing inconsistencies.
  • Review and analyze specific procedure and diagnosis codes for medical necessity.
  • Determine whether claimant’s plan covers the claim submitted and how much money, if any, should be paid.
  • Authorize payment, partial payment or denial of claim based upon individual investigation and analysis. (On a yearly basis, responsible for determining claims payments totaling millions of dollars on behalf of company clients.)
  • Review Workflow Manager daily to document and release pended claims.
  • Review Pended Claim Reports and close out pended claims for which no response has been received.
  • Review Suspended Claim Reports and follow up on open issues.
  • Process Adjustment Claims when necessary due to corrected claims.
  • Assist and support other claims adjusters as needed and when requested.
  • Attend continuing education classes as required, including but not limited to HIPAA training.


Communication – Communicates effectively both internally and externally, where applicable. Includes both written and verbal communication.

Customer Focused – Works well with customers/clients both internal and external, promotes a positive image of the company and department, and strives to solve issues raised by customers.

Dependability – Meets deadlines, works independently, accountable, maintains focus, punctual, and maintains good attendance record.

Initiative – Takes action independently, seeks new opportunities, and strives to see projects to completion.

Interpersonal Skills – Builds strong relationships, is flexible/adaptable, works well with others, and solicits feedback.

Job Knowledge – Understands the facets of job, aware of duties and responsibilities, and keeps job knowledge current.

Organization Skills – Information organized and accessible maintains efficient work space, and manages time well.

Problem Solving – Strives to understand contributing factors, works to resolve complex situations.

Productivity – Manages workload, works efficiently, and meets goals and objectives.

Self-Development – Looks for opportunities to increase knowledge, works to increase responsibility, strives to achieve personal goals and/or maintains licenses and other pertinent requirements.

Sense of Urgency – Meets deadlines, establishes appropriate priority, and completes tasks assigned in timely manner.

Teamwork – Accountable to team, works to meet established deliverables, appreciates view of team members, and respectful.

Technical Skills – Maintains current understanding of technical process/equipment, uses technology to increase performance/productivity; effectively uses online tools and resources.


Applicants must have a minimum of five (5) years of medical claims analysis experience (including dental and vision claims analysis), including recent claims processing experience within the last 3-5 years.

Third Party Administrator (TPA) claims processing experience and QicLink Systems experience preferred.


High School Diploma, some College Preferred, but not required.


All applicants must have strong analytical skills and knowledge of computer systems and CPT and ICD-9/ICD-10 coding terminology. Continuing education in all areas affecting group health and welfare plans is required.


This position is virtual with in-office training and continuing education hosted in Chicago and virtually.

At home work station must have high-speed internet connection, company will provide computer.

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

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