ZipRecruiter

Log In

1

Claim Processor Jobs in Miami, FL (NOW HIRING)

Lifeworks

Disability Assistant

Miami, FL · Remote

Processes incoming documents. * Reviews and analyzes FMLA and STD documents received and determines if all necessary information has been provided to proceed with claim assignment / processing.

Stellar Human Resource Services LLC

Claims

Miami, FL

The Claims Examiner is an exciting and challenging position that is the primary contact to our client throughout the claims process and help manage the investigation of their claim. The position will ...

previous page

Showing results 41-60

All JobsClaim Processor JobsClaim Processor Jobs in Miami, FL

Claim Processor information

See Miami, FL salary details

$11

$18

$25

How much do claim processor jobs pay per hour?

As of Aug 13, 2026, the average hourly pay for claim processor in Miami, FL is $18.33, according to ZipRecruiter salary data. Most workers in this role earn between $15.62 and $19.76 per hour, depending on experience, location, and employer.

What is a claim processor?

A Claim Processor is a professional who reviews and handles insurance claims submitted by policyholders or healthcare providers. Their main responsibilities include verifying the accuracy of claim information, ensuring all required documentation is provided, and determining whether a claim is valid under the policy terms. Claim Processors work with various types of insurance, such as health, auto, or property, and play a crucial role in ensuring timely and accurate payments. They may also communicate with customers, providers, and adjusters to resolve any discrepancies or additional information requests.

What do you need to be a claim processor?

To become a claim processor, candidates typically need a high school diploma or equivalent, strong attention to detail, and good organizational skills. Experience with insurance policies, claims processing software, or customer service can be beneficial, and some employers may require familiarity with specific tools or certifications related to insurance or claims management.

Is it hard to be a claim processor?

Claim processing is a detail-oriented job that requires strong organizational skills, attention to accuracy, and familiarity with claims management software. The difficulty can vary based on workload, complexity of claims, and experience level, but it generally involves routine tasks with some need for problem-solving and communication skills.

What are some typical challenges a claim processor might face in their daily work?

Claim Processors often handle high volumes of paperwork and data entry, which can be challenging when ensuring accuracy and meeting tight deadlines. They may also need to interpret complex policy details or resolve discrepancies in submitted claims, requiring strong attention to detail and problem-solving skills. Additionally, Claim Processors frequently interact with policyholders, healthcare providers, or other internal teams, so effective communication and the ability to manage stressful situations professionally are important for success.

What is the difference between Claim Processor vs Claims Examiner?

AspectClaim ProcessorClaims Examiner
Required CredentialsHigh school diploma or equivalent; some roles may require insurance certificationsHigh school diploma; insurance certifications preferred
Work EnvironmentOffice settings, insurance companies, healthcare providersOffice settings, insurance companies, healthcare providers
Employer & Industry UsageInsurance companies, healthcare providers, third-party administratorsInsurance companies, third-party administrators, government agencies
Job FocusProcessing insurance claims, data entry, verifying informationReviewing claims for accuracy, compliance, and coverage decisions

While both Claim Processors and Claims Examiners work within the insurance industry handling claims, Claim Processors primarily focus on data entry and initial processing of claims. Claims Examiners review claims for accuracy and compliance, making decisions on claim approval or denial. The roles often overlap, but Claims Examiners typically require more experience or certifications and perform more in-depth analysis.

What are the key skills and qualifications needed to thrive as a claim processor, and why are they important?

To thrive as a Claim Processor, you need strong attention to detail, analytical skills, and a basic understanding of insurance policies, usually supported by a high school diploma or equivalent. Familiarity with claims management software, data entry systems, and sometimes certification such as AIC (Associate in Claims) is common. Excellent organizational skills, clear communication, and the ability to handle sensitive information with discretion help individuals excel in this role. These skills ensure accurate and timely processing of claims, minimize errors, and maintain customer satisfaction and regulatory compliance.
What are the most commonly searched types of Claim Processor jobs in Miami, FL? The most popular types of Claim Processor jobs in Miami, FL are:
Claim Processor jobs near you
Infographic showing various Claim Processor job openings in Miami, FL as of August 2026, with employment types broken down into 80% Full Time, 18% Part Time, and 2% Contract. Highlights an 85% Physical, 5% Hybrid, and 10% Remote job distribution, with an average salary of $38,127 per year, or $18.3 per hour.

Lead Software Engineer Healthcare Payer SME -- CapAdmin Platform

Alivi

Miami, FL • On-site

$140 - $190/hr

Other

Posted 29 days ago

Job description

Job Summary

Alivi is seeking a Lead Software Engineer with deep healthcare payer domain expertise to join our CapAdmin platform team, our proprietary claims administration system supporting our TPA (Third-Party Administrator) operations. This is a hybrid technical‑SME leadership role designed to bridge the gap between engineering execution and payer / claims business knowledge. The ideal candidate is a senior engineer who has lived inside a payer or TPA platform, someone who understands not just how to build software, but how claims, eligibility, capitation, COB, UM, and UB04 workflows actually function in a real payer environment. This role will directly support our CapAdmin Development Lead, owning architecture, requirements validation, and SME‑level guidance ensuring features are built right the first time, with complete domain requirements captured before development begins.

Duties & Responsibilities 3.1 Healthcare Payer Domain Leadership (Primary Focus)

Serve as the internal SME for payer / TPA workflows, including:

  • UB04 / CMS-1500 institutional and professional claim form processing
  • Coordination of Benefits (COB) — primary, secondary, tertiary payer logic
  • Utilization Management (UM) — prior authorization, medical necessity, concurrent review integrations
  • Capitation models — PMPM calculations, cap reconciliation, risk pool accounting, sub-cap arrangements
  • Eligibility & enrollment (834 transactions)
  • Claims adjudication rules, edits, and pricing logic
  • EDI standards: 837, 835, 270/271, 276/277, 278

Translate complex payer business requirements into clear, complete technical specifications before development begins. Partner with Operations, Finance, and Compliance to validate claims and capitation logic end‑to‑end.

3.2 Technical Leadership
  • Partner with the CapAdmin Development Lead to drive architecture, scalability, and platform modernization.
  • Lead code reviews with a domain lens — catching not just code quality issues but business logic errors.
  • Mentor mid‑level developers on healthcare payer concepts they may not have prior exposure to.
  • Contribute to design and implementation of new product line integrations (Ophthalmology, expanded COB, etc.).
3.3 Requirements & Quality Ownership
  • Own the "requirements completeness" function — ensuring every feature has full payer-domain context before sprint commitment.
  • Work directly with Business Analysts, QA, and Product to eliminate the root cause of most CapAdmin defects: incomplete requirements.
  • Define and document acceptance criteria grounded in payer regulations and customer contracts.
3.4 Cross-Functional Collaboration
  • Partner with Operations leadership on claims accuracy, capitation reconciliation, and customer‑facing escalations.
  • Support customer‑facing technical conversations with payer clients (Sunshine Health, Humana, etc.) when domain expertise is needed.
  • Collaborate with the Architecture, Security, and Data / BI teams on enterprise alignment.
Requirements 4.1 Healthcare Payer / TPA Experience (Non‑Negotiable)
  • 7+ years working inside a payer platform, TPA system, or claims administration software (e.g., Facets, QNXT, HealthRules, HealthEdge, TriZetto, EZ‑CAP, or proprietary platforms).
  • Hands‑on experience with UB04 and CMS‑1500 claim processing.
  • COB rules and logic (NAIC order of benefits, Medicare secondary payer).
  • Utilization Management workflows.
  • Capitation models and reconciliation.
  • EDI transactions (837, 835, 834, 270/271, 278).
  • Working knowledge of CPT, HCPCS, ICD‑10, revenue codes, and place‑of‑service codes.
  • Familiarity with CMS, state Medicaid, and commercial payer requirements.
4.2 Technical Experience
  • 8+ years of professional software engineering experience.
  • Strong proficiency in C# / .NET, Java, or similar enterprise languages.
  • Solid experience with relational databases (SQL Server, PostgreSQL) and data modeling for claims / payer systems.
  • Experience with REST APIs, microservices, and integration patterns.
  • Familiarity with AWS (Redshift / AWS / QuickSight stack) is a strong plus.
  • Comfortable with Agile / Scrum, CI/CD, and modern DevOps practices.
4.3 Leadership & Communication
  • Demonstrated ability to mentor engineers and translate domain knowledge across technical and business audiences.
  • Strong written and verbal communication — able to participate in customer and executive‑level conversations.
  • Bilingual (English / Spanish) is a plus given our Miami‑based team.
5 Preferred Qualifications
  • Prior experience at a TPA, MSO, IPA, or health plan in a technical leadership role.
  • Experience with specialty benefits administration (vision, transportation, podiatry & therapy, etc.).
  • Familiarity with HITRUST, HIPAA, and HITECH compliance requirements for payer systems.
  • Experience supporting Medicaid managed care (e.g., Sunshine Health, Humana, Florida Medicaid).
  • Background in risk‑based contracts, sub‑capitation, and value‑based care arrangements.
#J-18808-Ljbffr

Apply