Claims HMO - Claims Examiner 140-1060

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 40,000 - 54,000; Full time

Job summary

CommunityCare HMO Inc. seeks a Claims Examiner to review claims prior to adjudication, using knowledge and tools to decide payments, denials or adjustments. The role emphasizes accuracy and efficiency in processing claims and supporting related departments.

The position requires reading medical terminology, CPT codes, and health benefit booklets, with strong attention to detail and ability to work with minimal direction. Equal opportunity employer.

Qualifications

• High School Diploma or Equivalent is required.
• Two years of related work experience in claims processing, data entry or medical billing.
• Ability to read and understand claims processing manuals, medical terminology, CPT codes, and health benefit booklets.

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.

Skills

Self-motivated

Claims processing

CPT codes knowledge

Health benefit booklets

Attention to detail

Oral and written communication

MS Office

Math calculations

Reading manuals

Team collaboration

Education

High School Diploma or Equivalent

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