Claims HMO - Claims Examiner 140-1059

CommunityCare, Inc.; Tulsa (OK); On-site; USD 35,000 - 55,000; Full time

Job summary

CommunityCare, Inc. is seeking a detail-oriented Claims Examiner to review and adjudicate claims prior to payment. You will determine payments, denials, or adjustments using standard guidelines and ensure accuracy and efficiency.

You will identify cases for escalation, input claim data, monitor trends, and support related teams. Strong CPT code knowledge and clear communication are essential.

Qualifications

• High School Diploma or Equivalent is required.
• Two years related work experience in claims processing or medical billing or a medical-related education.
• Knowledge of CPT codes and health benefit booklets.
• Ability to read claims processing manuals and perform basic processing procedures.
• Strong attention to detail and solid communication skills.

Responsibilities

• Examine and adjudicate claims that require review prior to adjudication.
• Enter claims information using processing software to compute payments, allowable amounts, limitations and denials.
• Identify claims needing additional resources and route to the appropriate person.
• Identify trends or issues during adjudication and communicate findings.
• Support team and other departments to maintain a positive work environment.
• Learn and adapt to changes related to claims processing and regulations.
• Perform other job-related duties as assigned.

Skills

Claims processing

Medical terminology

CPT codes

Attention to detail

Written communication

Microsoft Office

Education

High School Diploma or Equivalent

Two years related work experience in claims processing or medical billing

Tools

Microsoft Office

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.