Claims HMO - Claims Examiner 140-1008

CommunityCare, Inc.; Tulsa (OK); On-site; USD 42,000 - 64,000; Full time

Job summary

CommunityCare, Inc. seeks a Claims Examiner to review and adjudicate pended claims before payment. You will use manuals, CPT codes, and health benefit knowledge to determine actions and ensure accuracy in processing.

Responsibilities include routing complex claims, entering data into processing software, identifying trends, and supporting a collaborative team environment while staying current with changes in regulations and benefit terminology.

Qualifications

• Requires self-motivation and ability to work with minimal direction.
• Ability to read claims processing manuals, CPT codes, and medical terminology.
• Ability to read health benefit booklets.
• Demonstrated learning agility.
• Health care sanctions background check required.
• Knowledge of contracted managed care plan terms and rates.
• Understanding of unbundling methods, COB, and over-billing.

Responsibilities

• Review and adjudicate pended claims prior to adjudication.
• Route complex claims to team lead or other departments as needed.
• Enter claims information into processing software to compute payments and denials.
• Identify trends or problems during adjudication.
• Contribute to a pleasant working environment with peers and other departments.
• Assist in investigating and solving claims that require additional research.
• Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.
• Perform other job-related duties as assigned.

Skills

Claims processing

Attention to detail

Communication skills

Microsoft Office

Medical terminology

Math calculations

Education

High School Diploma

Job description

JOB SUMMARY:

The Claims Examiner is responsible for examining claims that require review prior to being adjudicated. The examiner will use their resources, knowledge and decision-making acumen to determine the appropriate actions to pay, deny or adjust the claim. Examiners are expected to meet performance expectations in accuracy and efficiency.

KEY RESPONSIBILITIES:

• Examining and adjudicating claims that have pended for review utilizing resources, tools, knowledge and decision-making in determining appropriate actions.
• Identify claims requiring additional resources and route to the team lead, supervisor or other departments as needed.
• Enter claims information using the processing software to compute payments, allowable amounts, limitations, exclusions and denials.
• Identify and communicate trends or problems identified during adjudication process.
• Contribute to the creation of a pleasant working environment with peers and other departments.
• Assist in investigating and solving claims that require additional research.
• Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.
• Perform other job-related duties as assigned.

QUALIFICATIONS:

• Self-motivated and able to work with minimal direction.
• Ability to read and understand claims processing manuals, medical terminology, CPT codes, and perform basic processing procedures.
• Ability to read and understand health benefit booklets.
• Demonstrated learning agility.
• Successful completion of Health Care Sanctions background check.
• Knowledge in the contracted managed care plan terms and rates.
• General understanding of unbundling methods, COB, and other over-billing methodologies.
• Must have high attention to detail.
• Proficient in Microsoft applications.
• Ability to perform basic mathematical calculations.
• Possess strong oral and written communication skills.

EDUCATION/EXPERIENCE:

• High School Diploma or Equivalent required.
• Two years related work experience in claims processing, claims data entry or medical billing OR medical related education to meet minimum two years required.