Claims HMO - Claims Examiner 140-1060

CommunityCare • Tulsa, OK

6d

About The Position

The Claims Examiner reviews claims that require examination before adjudication and determines whether to pay, deny, or adjust them using available resources, knowledge, and decision-making. The role is expected to meet accuracy and efficiency performance expectations. The examiner processes claims, identifies matters requiring additional resources or research, communicates trends and problems, and adapts to changes in claims processing, benefits, limits, and regulations. The position also contributes to a positive working environment and performs other job-related duties as assigned.

CommunityCare is an equal opportunity at-will employer and does not discriminate against employees or applicants on the basis of age, race, religion, color, disability, sex, sexual orientation, or national origin.

Requirements

• High school diploma or equivalent.
• Two years of related work experience in claims processing, claims data entry, or medical billing, or medical-related education sufficient to meet the two-year minimum.
• Self-motivated and able to work with minimal direction.
• Ability to read and understand claims processing manuals, medical terminology, CPT codes, and basic processing procedures.
• Ability to read and understand health benefit booklets.
• Demonstrated learning agility.
• Successful completion of a Health Care Sanctions background check.
• Knowledge of contracted managed care plan terms and rates.
• General understanding of unbundling methods, coordination of benefits (COB), and other over-billing methodologies.
• High attention to detail.
• Proficiency in Microsoft applications.
• Ability to perform basic mathematical calculations.
• Strong oral and written communication skills.

Responsibilities

• Examine and adjudicate claims pending review using appropriate resources, tools, knowledge, and judgment.
• Identify claims requiring additional resources and route them to a team lead, supervisor, or other department as needed.
• Enter claims information into processing software to calculate payments, allowable amounts, limitations, exclusions, and denials.
• Identify and communicate trends or problems found during the adjudication process.
• Contribute to a pleasant working environment with peers and other departments.
• Assist in investigating and resolving claims that require additional research.
• Learn and adapt to changes in claims processing, benefits, limits, and regulations.
• Perform other job-related duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED