Claims HMO - Claims Examiner 140-1060

CommunityCare; Tulsa (OK); On-site; USD 42,000 - 65,000; Full time

Job summary

CommunityCare is seeking a Claims Examiner to review and adjudicate claims prior to payment decisions. The role requires interpreting manuals, medical terminology, CPT codes and health benefit booklets to determine pay, deny or adjust actions.

The candidate should demonstrate learning agility, strong numerical and written communication skills, and the ability to work with minimal direction while maintaining accuracy. Equal opportunity employer.

Qualifications

• Read and interpret claims processing manuals and medical terminology.
• Understand health benefit booklets and apply benefit rules.
• Demonstrated learning agility and accuracy.
• Able to pass Health Care Sanctions background check.
• Knowledge of contracted managed care plan terms and rates.
• Familiar with unbundling methods, COB and over-billing concepts.
• Strong attention to detail and numerical accuracy.
• Proficient with Microsoft applications and basic math.
• Clear spoken and written communication.

Responsibilities

• Examine and adjudicate claims pending review to determine actions (pay/deny/adjust).
• Identify claims needing additional resources and route appropriately.
• Enter claims data using processing software to compute payments, allowances, and denials.
• Spot trends or issues during adjudication and communicate findings.
• Support a collaborative, pleasant work environment across teams.
• Assist in researching and resolving claims requiring effort.
• Keep up-to-date with changes in claims processing, benefits, limits, and regulations.
• Perform other related duties as assigned.

Skills

Self-motivated

Reading guidelines

Medical terminology

CPT codes

Health benefit booklets

Learning agility

Attention to detail

Microsoft Office

Math calculations

Communication skills

Managed care terms

COB/unbundling

Education

High School Diploma or Equivalent

Two years related work experience in claims processing/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.

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