Claims HMO - Claims Examiner 140-1058

Community Care • Tulsa, OK

7d

About The Position

The Claims Examiner reviews claims that require examination before adjudication and determines whether to pay, deny, or adjust each claim using available resources, knowledge, and judgment. The role is expected to meet performance standards for accuracy and efficiency.

The position examines and adjudicates pended claims, enters claim information into processing software, identifies cases requiring additional resources or research, and communicates trends or problems discovered during adjudication. The examiner also works cooperatively with peers and other departments and adapts to changes in claims processing, benefits, limits, and regulations.

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 meeting the minimum two-year requirement.
• 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 pended for review using available resources, tools, knowledge, and judgment to determine appropriate actions.
• Identify claims requiring additional resources and route them to a team lead, supervisor, or other department as needed.
• Enter claim information using 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 with 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
• Education Level: High school or GED