Claims HMO - Claims Examiner 140-1058

CommunityCare, Inc.; Tulsa, Northern (OK, KY); Hybrid; USD 40,000 - 60,000; Full time

Job summary

CommunityCare, Inc. in Tulsa, OK seeks a detail-oriented Claims Examiner to review and adjudicate claims prior to payment decisions.

The role emphasizes accuracy, efficiency, and compliance with benefits, limits, and regulations, including data entry, trend identification, and cross‑department collaboration.

Ideal candidates have a high school diploma and two years of related claims experience, with strong communication and math skills.

Qualifications

• Two years of related work experience in claims processing or medical billing
• High School Diploma or Equivalent required
• Ability to read and understand claims processing manuals, medical terminology, CPT codes
• Knowledge of health benefit booklets and regulations
• Demonstrated learning agility and accuracy in processing

Responsibilities

• Examine and adjudicate claims that have pended for review to determine actions (pay, deny, adjust).
• Identify claims needing additional resources and route to team lead or supervisor.
• Enter claims information using processing software to compute payments, benefits, exclusions and denials.
• Identify trends or problems during adjudication and communicate findings.
• Contribute to a positive working environment with peers and other departments.
• Assist in researching and resolving claims requiring additional investigation.
• Stay updated on changes related to claims processing, benefits, limits and regulations.

Skills

Self-motivated

Medical terminology

CPT codes

Reading health benefit booklets

Microsoft Office

Attention to detail

Numerical calculations

Written & verbal communication

Education

High School Diploma or Equivalent

Two years related work experience in claims processing or medical billing

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.