Top 267 Claims processing Jobs in Miami, Fl

Grievance and Appeals Analyst I
Sunscripts - OTC —Doral, FL
- $22 - $24 an hour
- Weekends as needed
- Ability to walk for extended periods
- English
- Research
- Health savings account
- Health insurance
Quick Apply
Provider Network Configuration Specialist
Solis Health Plans —Doral, FL
- $25 - $27 an hour
- Full-time
- English
- Mid-level
- Office
- Health savings account
- Dental insurance
Quick Apply
Claim Examiner I
Doral Office Services —Doral, FL
- $19 - $23 an hour
- Weekends as needed
- Background check
- Spanish
- Ability to walk for extended periods
- Health insurance
- Dental insurance
Quick Apply
Billing - Data Entry Maintenance
SERVICES ON-SITE —Miami, FL
- Microsoft Outlook
- Mid-level
- Administrative experience
- Paid holidays
- Health insurance
Quick Apply
10d
Healthcare Claims and Fee for Service Supervisor
Provider Network Solutions LLC —Miami, FL
- $63,000 - $65,000 a year
- Full-time
- 5 years
- HIPAA
- Bachelor's degree
Quick Apply
Claims Support Specialist
Global Excel Management —Miami, FL
- From $21 an hour
- Full-time
- Customer service
- English
- Mid-level
- Health insurance
- Dental insurance
Quick Apply
9d
Claims Processing Professional
OneHome —Miramar, FL
- $53,700 - $72,600 a year
- Full-time
- Spanish
- HIPAA
- English
- Paid parental leave
- Paid holidays
7d
Claims Representative
Redion —Pembroke Pines, FL
- Overtime
- Hybrid work
- Mid-level
- Communication skills
- Travel reimbursement
- Paid parental leave
Quick Apply
10d
Grievance and Appeals Analyst I
Solis Health Plans —Doral, FL
- $22 - $24 an hour
- Weekends as needed
- Ability to walk for extended periods
- Research
- Mid-level
Quick Apply
Medicaid Claims Examiner
DOCTORS HEALTHCARE PLANS, INC. —Coral Gables, FL
- Full-time
- Research
- Mid-level
- High school diploma or GED
Quick Apply
2d
Health System Specialist (Credentialing & Privileging)
US Veterans Health Administration —Miami, FL
- $65,735 - $85,460 a year
- Online Application
- Background check
- Psychiatry
- Writing skills
- On-the-job training
4d
Claims Adjudicator
National Healthcare Solutions, Inc. —Miami, FL
- Full-time
- Spanish
- Customer service
- Data analysis skills
Quick Apply
Business Office Specialist
BRISTOL HOSPICE - MIAMI DADE LLC —Miami, FL
- $21.50 - $23.00 an hour
- Full-time
- Word processing
- Computer literacy
- Office
- Mileage reimbursement
- Health savings account
Quick Apply
4d
Claims Correspondence Coordinator
Independent Living Systems —Miami, FL
- Full-time
- HIPAA
- Mid-level
- Office
Regulatory Analyst - Remote
University of Miami —Miami, FL
- Full-time
- Remote
- Databases
- Bachelor's degree
- Continuous improvement
- Health insurance
- Dental insurance
Fraud Specialist
BrightStar Credit Union —Cooper City, FL
- $23.80 - $29.32 an hour
- Full-time
- Bachelor of Science
- Mid-level
- Office
- Health savings account
- Health insurance
Claims & Billing Analyst
Independent Living Systems —Miami, FL
- Full-time
- HIPAA
- Mid-level
- Office
Payment Processing Specialist - 994374
Nova Southeastern University —Fort Lauderdale, FL
- Weekends as needed
- Background check
- Microsoft Outlook
- Customer service
- Health insurance
- Dental insurance
Pharmacy Technician - Refill Calls
Shields Health Solutions —Miami, FL
- $19 - $22 an hour
- Overtime
- Remote
- Microsoft Outlook
- High school diploma or GED
- Communication skills
- Paid parental leave
- Paid holidays
Quick Apply
Entry Level HR Clerk
Miami, FL —Miami, FL
- Weekends as needed
- Spanish
- Writing skills
- English
- Health savings account
- Health insurance
Quick Apply

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Grievance and Appeals Analyst I

Sunscripts - OTC -
Doral, FL

Quick Apply

Job Details

Full-time
$22 - $24 an hour

Benefits

Health savings account
Health insurance
Dental insurance
401(k)
Paid time off
Vision insurance
401(k) matching
Referral program

Qualifications

Customer communication
Medicare
Medical coding
Health insurance policy knowledge
CMS
Regulatory compliance in claims processing
English
Medical claims processing software
CMS regulatory compliance
Attention to detail
NCQA standards
Organizational skills
Productivity software
Medical terminology
Time management

Full Job Description

POSITION SUMMARY

The Grievance and Appeals Analyst I is responsible for the review, investigation, and resolution of member grievances and appeals within a managed-care health plan. Ensures all activities are conducted in compliance with regulatory requirements, including those established by the Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA). Supports timely, accurate, and compliant resolution of member and provider complaints while maintaining a high standard of customer service and operational excellence.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to:

Key Responsibilities

Conducts comprehensive review, investigation, and resolution of member grievances, appeals, and complaints in accordance with CMS, NCQA, and state regulatory guidelines.
Research and analyze claims, benefit plans, authorizations, and supporting documentation to determine appropriate outcomes.
Ensures all cases are processed within mandated regulatory and internal timelines.
Requests, reviews, and interprets medical records, provider documentation, and itemized bills as needed to support case determinations.
Applies contract language, benefit structures, medical policies, and coverage guidelines to grievance and appeals decisions.
Collaborates with internal departments (e.g., Medical Management, Provider Relations, Compliance) to ensure accurate and consistent resolutions.
Identifies root causes of issues, including claims processing errors, system configuration discrepancies, or Provider billing concerns.
Prepares clear, concise, and compliant written correspondence to members, providers, and authorized representatives outlining determinations.
Documents all case activity, findings, and outcomes in accordance with audit and regulatory requirements.
Tracks and reports trends in grievances and appeals to support quality improvement initiatives.
Communicates with members and providers via written and verbal channels to obtain additional information or clarify case details.
Meets or exceeds departmental productivity and quality performance standards.

QUALIFICATIONS AND EDUCATION

Required Qualifications

Minimum of 2 years of experience in managed care, healthcare appeals, grievances, or claims processing; or equivalent combination of education and experience.
Working knowledge of Medicare and/or Medicaid regulations, including CMS guidelines for appeals and grievances.
Understanding of NCQA standards related to member complaint and appeals processes.
Experience reviewing claims, including eligibility, coordination of benefits (COB), and denial management.
Strong analytical and problem-solving skills with attention to detail.
Excellent written and verbal communication skills, with the ability to compose regulatory-compliant correspondence.
Strong organizational and time management skills with the ability to manage multiple priorities and meet strict deadlines.
Proficiency in Microsoft Office applications and relevant claims or case management systems.

Preferred Qualifications

Experience working in a managed care organization supporting Medicaid, Medicare Advantage, or Marketplace plans.
Familiarity with medical terminology, coding, and utilization management processes.
Prior experience handling complex or escalated grievance and appeals cases.
Background in a healthcare setting such as a hospital, provider office, or health plan operations.

WORKING CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.
Works in the field
Interacts with patients, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

PERFORMANCE MEASUREMENT

Duties accomplished at the end of the day/month.
Attendance/punctuality.
Compliance with Company regulations.
Safety and Security.
Quality of work.

This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

Employee Acknowledgement:

I have read this job description and understand what is expected of me while I occupy this role.

Pay: $22.00 - $24.00 per hour

Benefits:

401(k)
401(k) matching
Dental insurance
Health insurance
Health savings account
Paid time off
Referral program
Vision insurance

Language:

English (Preferred)

Location:

Doral, FL 33178 (Preferred)

Ability to Commute:

Doral, FL 33178 (Preferred)

Work Location: In person

Quick Apply

Refine Your Search

claims processing jobs in miami, fl

Grievance and Appeals Analyst I

Provider Network Configuration Specialist

Claim Examiner I

Billing - Data Entry Maintenance

Healthcare Claims and Fee for Service Supervisor

Claims Support Specialist

Claims Processing Professional

Claims Representative

Grievance and Appeals Analyst I

Medicaid Claims Examiner

Health System Specialist (Credentialing & Privileging)

Claims Adjudicator

Business Office Specialist

Claims Correspondence Coordinator

Regulatory Analyst - Remote

Fraud Specialist

Claims & Billing Analyst

Payment Processing Specialist - 994374

Pharmacy Technician - Refill Calls

Entry Level HR Clerk

I want to receive the latest job alert for claims processing in miami, fl

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