Claims HMO - Senior Claims Examiner

CommunityCare • Tulsa, OK

2d

About The Position

The Senior Claims Examiner reviews and examines claims requiring additional analysis before adjudication. Using established resources, technical knowledge, and sound judgment, the role determines whether claims should be paid, denied, or adjusted while meeting accuracy, productivity, and efficiency standards. The position typically handles complex claims involving multiple lines of business and may assume ongoing responsibilities beyond general claims examination.

Requirements

• High school diploma or equivalent.
• At least two years of experience in medical claims processing.
• Self-motivated and able to work independently with minimal direction.
• Ability to interpret and apply claims processing manuals, medical terminology, CPT codes, and established processing procedures.
• Ability to read, interpret, and apply information contained in health benefit booklets.
• Demonstrated learning agility and ability to adapt to changing processes, systems, and requirements.
• Knowledge of contracted managed care plan terms, provisions, and reimbursement rates for multiple lines of business.
• General knowledge of unbundling practices, coordination of benefits (COB), and other potential overbilling methodologies.
• Strong attention to detail and commitment to accuracy.
• Proficiency with Microsoft Office applications.
• Ability to perform basic mathematical calculations accurately.
• Strong verbal and written communication skills.
• Successful completion of a Health Care Sanctions background check.

Responsibilities

• Examine and adjudicate complex or specialized claims pended for review across multiple lines of business, applying benefit provisions, processing guidelines, reimbursement methodologies, and sound judgment.
• Enter and validate claim information in processing systems to determine payments, allowable amounts, benefit limitations, exclusions, and denials.
• Identify, document, and communicate trends, processing issues, or recurring problems observed during claim adjudication.
• Resolve unique or complex claims situations independently and determine when escalation to a team lead, supervisor, or another department is appropriate.
• Maintain current knowledge of changes to claims processing procedures, benefit provisions, limitations, regulatory requirements, and applicable guidelines, and adapt processes accordingly.
• Assist with training, mentoring, and developing Claims Examiners; provide guidance on claims processing procedures, benefit provisions, system functionality, and complex claim scenarios.
• Perform other job-related duties as required or assigned.

What This Job Offers

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