Certified Claims Processor I

Allcare-Health; Grants Pass (OR); On-site; USD 28,000 - 33,000; Full time

Benefits offered by this job

Affordable healthcare

401k retirement

Wellness programs

Flexible schedule options

Job summary

AllCare Health in Grants Pass, Oregon is hiring a Certified Claims Processor I to adjudicate professional claims (CMS-1500) and apply CPT, HCPCS, and ICD-10 coding per contract terms and regulatory guidelines.

You will review pending claims, resolve denials, ensure HIPAA compliance, and collaborate with providers and internal teams to achieve accurate, timely adjudication. AAPC or AHIMA coding certification is required, with prior experience in medical terminology and claims processing.

Qualifications

• Associate's degree required.
• Six months to one year related experience in Medical Terminology, ICD-10CM, ICD10PCS.
• CMS1500 and UB04 experience required.
• Current AAPC or AHIMA Coding Certification required.
• Ability to perform essential duties with or without accommodation.

Responsibilities

• Independently adjudicates professional claims (CMS-1500) by applying benefits, pricing, coding guidelines, and contract terms.
• Reviews and resolves claim edits, denials, adjustments, and reprocessing requests.
• Interprets CPT, HCPCS, and ICD-10 coding to determine outcomes, including pricing, payment, and denial decisions.
• Ensures HIPAA compliance and protects PHI during all claim handling.
• Coordinates COB by reviewing member eligibility and payer responsibility.

Skills

CPT coding

HCPCS coding

ICD-10 coding

Attention to detail

HIPAA compliance

Microsoft Office

Communication skills

Education

Associate's degree (AA) or equivalent

Tools

CMS1500

UB04

Job description

AllCare Health Headquarters, Grants Pass, OR, US

6 days ago Requisition ID: 1228

Salary Range: $20.00 To $24.00 Hourly

Certified Claims Processor I at AllCare Health with the Claims department in Grants Pass, Oregon

We Are Seeking Qualified Candidates to Join Our Team!

AllCare Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and flexible schedule options.

Summary of the Position

The Certified Claims Processor I is responsible for independently adjudicating professional claims in accordance with company policy, contract language, and applicable regulatory guidelines. This role applies coding knowledge and established claims processing standards to resolve standard and moderately complex claims while ensuring accuracy, compliance, and timely adjudication.

• Independently adjudicates professional claims (CMS-1500) by applying benefits, pricing, coding guidelines, and contract terms.
• Utilizes knowledge of CPT, HCPCS, and ICD-10 coding to ensure accurate claims processing.
• Reviews and resolves pending claims, identifying errors and determining appropriate corrective action.
• Ensures compliance with company policy, provider contracts, and applicable Medicare/Medicaid regulations.
• Maintains established quality, accuracy, and production standards.

Job Duties

• Processes professional claims across multiple lines of business by reviewing claim and line-level details to ensure accurate adjudication in accordance with established policies and procedures.
• Interprets and applies coding guidelines (CPT, HCPCS, ICD-10), benefit plans, and contract language to determine appropriate claim outcomes, including pricing, payment, and denial decisions.
• Reviews and resolves claim edits, denials, adjustments, and reprocessing requests by analyzing claim and line-level data, including potential coding discrepancies, system configuration issues, or policy misalignment.
• Applies benefit plans, reimbursement methodologies, and regulatory requirements to ensure accurate outcomes.
• Evaluates pending claims to identify root causes of processing issues, including eligibility discrepancies, authorization requirements, or billing errors, and determines appropriate corrective actions.
• Coordinates benefits by reviewing member eligibility, other insurance information, and payer responsibility to ensure accurate application of coordination of benefits (COB) rules.
• Reviews provider disputes, reconsiderations, and appeals by analyzing original claim processing, supporting documentation, and applicable policies to determine if reprocessing or adjustment is warranted.
• Applies knowledge of reimbursement methodologies, fee schedules, and pricing logic to ensure claims are paid in accordance with contract terms and regulatory guidelines.
• Identifies trends or recurring issues in claim processing, including system errors, configuration gaps, or provider billing patterns, and escalates findings to leadership as appropriate.
• Communicate effectively with internal teams and providers to clarify claim details, explain adjudication outcomes, and resolve processing issues in a professional and timely manner.
• Maintains compliance with HIPAA and protects PHI by ensuring all claim handling, communication, and documentation meet confidentiality and security standards.
• Adheres to claim routing, inventory control procedures, and workflow processes to ensure timely and accurate claim processing within established turnaround times.
• Participates in ongoing training and continuing education to maintain coding certification and stay current with changes to coding guidelines, reimbursement methodologies, and regulatory requirements.
• Maintains punctual, regular, and predictable attendance while meeting established productivity and quality benchmarks.
• Respectfully takes direction from Department leadership.
• Performs other duties as assigned.

On Call Responsibilities

This position does not have any on-call responsibilities.

Supervisory Responsibilities

This position does not have any supervisory responsibilities.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Education

Associate's degree (AA) from a two-year college or technical school in equivalent combination of education and experience is required.

Experience

• Six months to one-year related experience and/or training in Medical Terminology, ICD-10CM, ICD10PCS,
• CMS1500 and UB04 and other claim forms are required.
• EZ-Cap experience preferred.

Certificates, Licenses, and/or Registrations

Current AAPC or AHIMA Certification Coding Certification Required (CPC, CPC-P)

Technical Skills

• Familiarity with the Healthcare industry.
• Excellent organization and time-management skills.
• Excellent computer skills, including the Microsoft Office Suite (Outlook, Word, PowerPoint, and Excel).
• Knowledge of and compliance with HIPAA regulations.

Interpersonal Skills

• Demonstrate accountability, inspiring trust and confidence from others.
• Work with high initiative, energy and effectiveness in a fast-past environment.
• Collaborate within a multidisciplinary, diverse team to provide professional service.
• Interact positively with customers to satisfy needs and resolve problems in a pleasant and professional manner.
• Prioritize and organize work according to competing timelines.
• Allocate your time so that you can complete tasks within established deadlines.
• Adapt to change, learn quickly, and work with ambiguity.
• Maintain an attentive and empathetic demeanor.
• Maintain a high degree of professionalism and confidentiality.
• Take initiative and apply sound judgment in completing tasks and responsibilities.

Language Skills

Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.

Mathematical Skills

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage and to draw and interpret bar graphs.

Computer Skills

Has advanced basic computer job skills including logging on to systems, ability to communicate by email, ability to compose documents, enter database information, create presentations, download forms, and preserve/backup important data.

Reasoning Ability

Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to work with problems involving a few concrete variables in standardized situations.

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this job. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

The employee must occasionally lift and/or move up to 10 pounds. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand; walk and reach with hands and arms. The noise level in the work environment is usually moderate.

• The employee must be able to work onsite, as needed.
• The employee may be able to work from a home office occasionally.

Company Overview

AllCare Health Website: https://www.allcarehealth.com .

AllCare Health is incorporated as an Oregon Benefit Corporation and has earned the coveted Certified B Corp status since 2017. As such, AllCare Health considers its impact on community, society, and the environment in all business decisions. We have long recognized the value in social, economic, and environmental concerns of our employees, customers, and community members. (Learn more about B Corps at https://bcorporation.net/about-b-corps )

AllCare Health headquarters are located in Grants Pass in Southern Oregon on the Rogue River, surrounded by mountains, forests, small farms, and breathtaking views. This thriving and energetic community is ideal for families and outdoor enthusiasts, with a temperate Pacific Northwest climate. We enjoy easy access to outdoor sports and recreation, river rafting, fishing, hiking, biking, wineries, outdoor concerts, the world-famous Ashland Shakespeare Festival, the stunning Oregon coast, magnificent redwood forests, pristine beaches, and much more.

The AllCare Health family of businesses is guided by our corporate principles:

Purpose | Working together with our communities to improve the health and well-being of everyone.

Values | Trust, Innovation, Relationships, and Voice.

Vision | Thriving, Inclusive, and Equitable communities.

Brand Promise | Changing Healthcare to Work for You.

AllCare Health is dedicated to building a diverse and authentic workplace centered in belonging and serving our growing community. If you are excited about this open position but your experience does not align perfectly with every qualification in this post, we encourage you to apply anyway or reach out to our human resources department. You may just be the right candidate for this role or others.

If you need accommodations, help in the application process, or wish to receive this job announcement in an alternative format, please call 541-471-4106 and ask for Human Resources.

All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sexual orientation, gender identity, sex, age, protected veteran or disabled status, or genetic information.

Monday-Friday with a 1 hour unpaid lunch and two 15 minute paid breaks
40 hours