Claims HMO - Claims Examiner 140-1060

CommunityCare, Inc.; Tulsa (OK); On-site; USD 38,000 - 52,000; Full time

Job summary

CommunityCare, Inc. is seeking a Claims Examiner to review and adjudicate medical claims prior to payment. The role relies on knowledge of CPT codes, health benefit booklets and processing manuals to determine pay, denial or adjustments.

You will analyze pended claims, route complex cases to leads, input data into processing software, and monitor trends. Strong attention to detail and communication skills are essential. Two years related experience or equivalent education are required.

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 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.

Responsibilities

• Examining and adjudicating claims that have pended for review.
• Identify claims requiring additional resources and route to the team lead or supervisor as needed.
• Enter claims information using processing software to compute payments, allowable amounts, limitations and denials.
• Identify and communicate trends or problems identified during adjudication.
• Contribute to a pleasant working environment with peers and other departments.
• Assist in investigating and solving claims that require additional research.
• Continuously learn and adapt to changes related to claims processing, benefits, limits and regulations.
• Perform other job-related duties as assigned.

Skills

Self-motivated

Attention to detail

Strong communication

Math basics

CPT codes familiarity

Education

High School Diploma or Equivalent

Two years related claims experience or medical billing education

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.