Claims Examiner II

CareOregon

7d • $23 - $28 • Remote

About The Position

The Claims Examiner II is an intermediate level position responsible for the timely review, investigation and adjudication of all types of Medicaid, Medicare, group and individual medical, dental, and mental health claims. Estimated Hiring Range: $22.82 - $27.89 Bonus Target: Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

Requirements

• Minimum 2 years’ experience as a Medical Claims Examiner or other role that requires knowledge of medical coding and terminology (e.g., medical billing, prior authorizations, appeals and grievances, health insurance customer service, etc.)
• Knowledge of CPT, HCPCS, Revenue, CDT and ICD-10 coding
• Knowledge of medical, dental, mental health and health insurance terminology
• Understanding of or ability to learn state and federal laws and other regulatory agency requirements that relate to medical, dental, mental health and health insurance industry and Medicaid/Medicare industry
• Ability to perform fast and accurate data entry
• Strong spoken and written communication skills
• Basic computer skills (ability to use Microsoft Outlook, Word and Excel) and learn new systems as needed
• Good customer service skills
• Ability to participate fully and constructively in meetings
• Strong analytical and sound problem-solving skills
• Detail orientation
• Strong organizational skills and time management skills
• Ability to work in a fast-paced environment with multiple priorities
• Ability to work effectively with diverse individuals and groups
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, hear, speak, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to lift, carry, reach, and/or pinch small objects for at least 1-3 hours/day

Nice To Haves

• Experience using QNXT, Facets, Epic systems

Responsibilities

• Adjudicate medical, dental and mental health claims in accordance and compliance with plan provisions, state and federal regulations, and CareOregon policies and procedures.
• Re-adjudicate, adjust or correct claims, including some complex and difficult claims as needed.
• Consistently meet or exceed the quality and production standards established by the department and CareOregon.
• Provide excellent customer service to internal and external customers.
• Collaborate and share information with Claims teams and other CareOregon departments to achieve excellent customer service and support organizational goals.
• Determine eligibility, benefit levels and coordination of benefits with other carriers; recognize and escalate complex issues to the Lead or Supervisor as needed.
• Investigate third party issues as directed.
• May review, process and post refunds and claim adjustments or re-adjudications as needed.
• Report any overpayments, underpayments or other possible irregularities to the Lead or Supervisor as appropriate.
• Generate letters and other documents as needed.
• Proactively identify ways to improve quality and productivity.
• Continuously learn and stay up to date with changing processes, procedures and policies.

Benefits

• We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package.
• Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours.
• Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date.
• CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.).
• We also offer a strong retirement plan with employer contributions.
• Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state.
• Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility.
• Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 1,001-5,000 employees