Claims HMO - Lead Recalculation Examiner PC# 140-1019

Community Care•Tulsa, OK

About The Position

The Lead Recalculation Examiner works directly with the Claims Supervisor to help the team work efficiently and achieve its potential. The role provides guidance, instruction, and training to claims department employees, helps resolve complex claims situations and escalated problems, and may serve as a liaison between Claims and other departments. The position focuses on developing team members’ skills and knowledge so they can better support customers and the company’s mission. The Lead coordinates daily workflow, communicates relevant changes, helps motivate and support employees, and identifies training needs. The role also processes and reviews claims, investigates coordination of benefits and other coverage, performs related clerical work, and adapts to changes in claims processing, benefits, limits, and regulations.

Requirements

High school diploma or equivalent.
Three years of related work experience in claims processing, data entry, or medical billing.
One year of claims processing experience within CommunityCare or another healthcare environment.
Self-motivated and able to work with minimal direction.
Ability to read and understand claims processing manuals and medical terminology, understand CPT codes, and perform claims processing procedures.
Knowledge of contracted managed care plan terms and rates.
General understanding of unbundling methods, coordination of benefits, and other over-billing methodologies.
Ability to motivate and coach employees and deliver performance-improvement feedback.
Excellent written and verbal communication skills.
Demonstrated learning agility.
Strong relationship-building skills.
Proficiency in Microsoft applications.
Strong organizational and time-management skills, with attention to detail.
Knowledge of claims processing manuals and health benefit booklets.
Ability to maintain quality and production guidelines.
Successful completion of a Health Care Sanctions background check.
Knowledge of Network Authorization requirements.

Responsibilities

Coordinate daily workflow among employees and provide updates to the supervisor.
Assist the supervisor in regularly communicating changes that affect employees’ inquiry responses.
Solve problems while balancing company and customer needs.
Motivate the team to achieve organizational goals and contribute to company growth.
Help create a pleasant working environment that inspires the team.
Identify training needs and train staff on claims and company policies.
Enter claims information in claims software to process claim payments, allowable amounts, limitations, exclusions, and denials, and review system adjudications for errors.
Review and investigate appropriate claims involving coordination of benefits, workers’ compensation, and third-party coverage.
Perform clerical duties related to claims processing and completion, including pending letters and requests to load information for providers, members, or authorizations.
Handle the most difficult or complex claims and claims situations requiring significant experience and knowledge.
Learn and adapt to changes in claims processing, benefits, limits, and regulations.
Assist the Claims Supervisor with additional duties as needed or directed.