Claims HMO - Claims Examiner 140-1059

CommunityCare; Tulsa (OK); On-site; USD 40,000 - 60,000; Full time

Job summary

CommunityCare is seeking a Claims Examiner to review and adjudicate claims prior to adjudication, applying knowledge of CPT codes and health benefit terms. The role supports accuracy and efficiency in processing and requires strong attention to detail.

Responsibilities include routing complex claims, entering data into processing systems, and communicating trends. A background check is required, with a focus on compliance and process improvement within a collaborative team environment.

Qualifications

• Must understand claims processing manuals and medical terminology.
• Familiar with CPT codes and basic processing procedures.
• Ability to read health benefit booklets.
• Demonstrated learning agility.
• Background check for Health Care Sanctions completed.
• Knowledge of managed care plan terms and rates.
• Understanding of unbundling methods, COB and over-billing.
• Strong attention to detail.
• Proficient with Microsoft Office applications.
• Ability to perform basic mathematical calculations.
• Strong oral and written communication skills.

Responsibilities

• Examine and adjudicate claims that are pending review to determine actions.
• Identify claims needing additional resources and route to team lead or supervisor.
• Enter claims information using processing software to compute payments, allowances, and denials.
• Identify and communicate trends or problems found during adjudication.
• Contribute to a collaborative, pleasant working environment with peers and other departments.
• Assist in investigating and solving claims requiring additional research.
• Continuously learn and adapt to changes in claims processing, benefits, limits and regulations.
• Perform other job-related duties as assigned.

Skills

Self-motivated

Claims processing literacy

Health care manuals & CPT

Health-benefit booklets

Learning agility

Background check compliance

Managed care knowledge

Unbundling & COB knowledge

Attention to detail

Microsoft Office

Basic math

Oral & written communication

Education

High School Diploma or Equivalent

2 years related experience in claims processing or medical billing (education acceptable)

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.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin