Claims Adjudication Specialist

CommunityCare; Tulsa (OK); On-site; USD 42,000 - 65,000; Full time

Job summary

CommunityCare is seeking a Claims Examiner to review and adjudicate claims prior to payment decisions. The role requires interpreting manuals, medical terminology, CPT codes and health benefit booklets to determine pay, deny or adjust actions.

The candidate should demonstrate learning agility, strong numerical and written communication skills, and the ability to work with minimal direction while maintaining accuracy. Equal opportunity employer.

Qualifications

• Read and interpret claims processing manuals and medical terminology.
• Understand health benefit booklets and apply benefit rules.
• Demonstrated learning agility and accuracy.
• Able to pass Health Care Sanctions background check.
• Knowledge of contracted managed care plan terms and rates.
• Familiar with unbundling methods, COB and over-billing concepts.
• Strong attention to detail and numerical accuracy.
• Proficient with Microsoft applications and basic math.
• Clear spoken and written communication.

Responsibilities

• Examine and adjudicate claims pending review to determine actions (pay/deny/adjust).
• Identify claims needing additional resources and route appropriately.
• Enter claims data using processing software to compute payments, allowances, and denials.
• Spot trends or issues during adjudication and communicate findings.
• Support a collaborative, pleasant work environment across teams.
• Assist in researching and resolving claims requiring effort.
• Keep up-to-date with changes in claims processing, benefits, limits, and regulations.
• Perform other related duties as assigned.

Skills

Self-motivated

Reading guidelines

Medical terminology

CPT codes

Health benefit booklets

Learning agility

Attention to detail

Microsoft Office

Math calculations

Communication skills

Managed care terms

COB/unbundling

Education

High School Diploma or Equivalent

Two years related work experience in claims processing/medical billing

Job description

CommunityCare is seeking a Claims Examiner to review and adjudicate claims prior to payment decisions. The role requires interpreting manuals, medical terminology, CPT codes and health benefit booklets to determine pay, deny or adjust actions.

The candidate should demonstrate learning agility, strong numerical and written communication skills, and the ability to work with minimal direction while maintaining accuracy. Equal opportunity employer.