Claims Examiner Lead

CareOregon•Washington, DC

5d•$25 - $31•Remote

About The Position

Claims Examiner Lead --------------------------------------------------------------- The Claims Examiner Lead works under the direction of the Claims Examiner Supervisor to manage the daily operations of the Claims Examiner team. This position is responsible for assisting with work distribution, individual performance tracking, and measuring competency and production levels. The role is also responsible for responding to technical questions from claims examiners and assisting the supervisor in implementing new processes, procedures, and may perform some auditing. This position may provide training to internal users on the plan benefit matrix and claims policies/procedures as well as provide assistance to the Claims Department leadership team. Duties include processing claims and acting as a role model for the staff. Estimated Hiring Range: $25.42 - $31.07 Bonus Target: Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job. --------------------------------------------------------------- Essential Responsibilities Evaluate complex and difficult medical, dental, and behavioral health claim which may result in adjudication, re-adjudication or adjustments of claims in accordance and/or compliance with plan provisions, State/Federal regulations, and CareOregon policies/procedures. Provide excellent customer service to internal and external customers. Utilize CareOregon on-line phone tracking system to document all activities from any mode of communication as defined by CareOregon and Claim Department policies. Consistently meet or exceed Department and Company policies including but not limited to quality, production, attendance, conduct. Determination eligibility, benefit levels, coordination of benefits with other carriers, recognize and investigate third party issues which may require working with attorneys or outside agents. Assist the claims supervisor in mentoring new or existing claims examiners which includes auditing employee work, identifying ways in which quality and productivity can be improved, and adjustments can be minimized. Assist claims examiners with claims processing and other questions. Continuously learn and stay up to date with changing processes, procedures and policies. Proactively work to build and improve the team. Independently manage special projects as assigned by the supervisor. Identify trends and communicate findings and process improvement ideas to the supervisor. Work collaboratively with other CareOregon departments to ensure timely, accurate, and effective claims adjudication. May develop reference documentation for department use. Provide training to new employees on specific tasks related to their job responsibilities. Coordinate with departments and external vendors to ensure all aspects of the projects have been appropriately addressed. Employee Leadership Provide leadership for a team in support of team direction and goals. Provide input into staffing needs; assist in recruiting and hiring staff, using an equity, diversity, and inclusion lens. Participate in organizing, scheduling, monitoring and improving work; help ensure employees have information to meet job expectations and have coverage during absences. Contribute to the development, communication, and oversight of team and individual goals. Train, lead, and coach employees; may facilitate team meetings. Incorporate guidance from CareOregon equity tools into people leadership. Help monitor employee adherence to department and organizational standards, policies, and procedures. Assist in evaluating employee performance, providing feedback to support success, recognizing strong performance, and addressing performance gaps and accountability (corrective action). Perform lead tasks in collaboration with Human Resources as needed.

Requirements

Minimum 3 years’ experience as a medical claims processor in the health insurance industry
In-depth knowledge of claims adjudication principles and procedures
Advanced knowledge of CPT, HCPCS, Revenue, DPT and ICD-9 coding
Strong knowledge of medical, dental, mental health and health insurance terminology
Knowledge, including completion requirements, of CMS and UB-92 claim forms
Strong understanding of federal and state laws and other regulatory agency requirements that relate to the medical, dental, mental health and health insurance industry or Medicaid/Medicare industry
Ability to proactively identify and work to improve the team’s quality and productivity
Ability to take the initiative to see beyond the original request and complete appropriate next steps
Ability to use strong analytical and critical thinking skills in solving problems
Ability to work well under pressure in a complex and rapidly changing environment
Strong written and oral communication skills
Excellent interpersonal skills
Excellent customer service skills
Strong organizational and time management skills
Ability to effectively manage multiple tasks and to remain flexible in a dynamic work environment
Strong multidisciplinary collaborative skills
Ability to be a positive and influential role model for other department members
Ability to assess training needs and may organize and conduct training sessions
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, and perform repetitive finger and wrist movement for at least 6 hours/day
Ability to hear and speak clearly for at least 3-6 hours/day

Nice To Haves

Experience with people and/or project leadership

Responsibilities

Evaluate complex and difficult medical, dental, and behavioral health claim which may result in adjudication, re-adjudication or adjustments of claims in accordance and/or compliance with plan provisions, State/Federal regulations, and CareOregon policies/procedures.
Provide excellent customer service to internal and external customers.
Utilize CareOregon on-line phone tracking system to document all activities from any mode of communication as defined by CareOregon and Claim Department policies.
Consistently meet or exceed Department and Company policies including but not limited to quality, production, attendance, conduct.
Determination eligibility, benefit levels, coordination of benefits with other carriers, recognize and investigate third party issues which may require working with attorneys or outside agents.
Assist the claims supervisor in mentoring new or existing claims examiners which includes auditing employee work, identifying ways in which quality and productivity can be improved, and adjustments can be minimized.
Assist claims examiners with claims processing and other questions.
Continuously learn and stay up to date with changing processes, procedures and policies.
Proactively work to build and improve the team.
Independently manage special projects as assigned by the supervisor.
Identify trends and communicate findings and process improvement ideas to the supervisor.
Work collaboratively with other CareOregon departments to ensure timely, accurate, and effective claims adjudication.
May develop reference documentation for department use.
Provide training to new employees on specific tasks related to their job responsibilities.
Coordinate with departments and external vendors to ensure all aspects of the projects have been appropriately addressed.
Provide leadership for a team in support of team direction and goals.
Provide input into staffing needs; assist in recruiting and hiring staff, using an equity, diversity, and inclusion lens.
Participate in organizing, scheduling, monitoring and improving work; help ensure employees have information to meet job expectations and have coverage during absences.
Contribute to the development, communication, and oversight of team and individual goals.
Train, lead, and coach employees; may facilitate team meetings.
Incorporate guidance from CareOregon equity tools into people leadership.
Help monitor employee adherence to department and organizational standards, policies, and procedures.
Assist in evaluating employee performance, providing feedback to support success, recognizing strong performance, and addressing performance gaps and accountability (corrective action).
Perform lead tasks in collaboration with Human Resources as needed.

Benefits

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package.
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.

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