Claims HMO - Claims Examiner 140-1060

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

Job summary

CommunityCare HMO Inc. is seeking a Claims Examiner in Tulsa, OK to review claims prior to adjudication. The examiner will apply resources, knowledge, and decision-making to determine payments, denials, or adjustments with accuracy and efficiency.

The role requires reading claims processing manuals and health benefit terminology, CPT codes, and performing basic data entry and calculations. Candidates should be self-motivated with attention to detail and proficient in Microsoft Office.

Qualifications

• Two years related work experience in claims processing, data entry or medical billing.
• Strong understanding of CPT codes and health benefit terminology.
• Ability to read claims processing manuals and health benefit booklets.

Responsibilities

• Examine and adjudicate claims pending for review to determine payments or denials.
• Identify claims needing additional resources and route to the appropriate supervisor or department.
• Enter claims information using processing software to compute payments, allowable amounts, limitations and denials.
• Identify and communicate trends or problems seen during adjudication.
• Support peers and other departments to maintain a pleasant work environment.
• Assist in investigating and solving claims requiring additional research.
• Continuously adapt to changes in claims processing, benefits, limits and regulations.
• Perform other job-related duties as assigned.

Skills

Claims processing

Medical terminology

CPT codes

Data entry

Microsoft Office

Two years related work experience in p

Education

High School Diploma or Equivalent

Tools

Processing software

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.

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