Claims HMO - Recalculation Examiner 140-1036

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

Job summary

CommunityCare HMO Inc. in Tulsa, OK is seeking a Recalculation Examiner to research and reprocess claims previously adjudicated.

The role requires evaluating provider submissions, processing corrections, and ensuring accurate pay/deny/adjust decisions with a focus on accuracy and efficiency. Typical responsibilities include handling first level appeal letters, refunds for overpayments, and coordinating with multiple departments to resolve issues while staying compliant with plan terms and

Qualifications

• Must be self-motivated with minimal direction.
• Ability to read claims processing manuals, understand CPT codes, and perform processing procedures.
• Knowledge of health benefit booklets and plan terms.
• Proficient in Microsoft Office and basic data entry.
• Strong attention to detail and written/oral communication skills.

Responsibilities

• Researches and reprocesses claims across multiple internal departments.
• Verifies corrected claim submissions and redirects to processing staff as needed.
• Performs clerical duties including first level appeal letters.
• Responds to first level inquiry appeals received by mail.
• Determines overpayments and completes refund paperwork.
• Maintains inventory tracking log and follows up on routed claims.
• Interfaces with departments to resolve corrections and system issues.
• Identifies trends or problems during adjudication.
• Resolves most unique problems without supervisor involvement.
• Contributes to a collaborative, pleasant work environment.
• Adapts to changes in claims processing, benefits, limits and regulations.
• Performs other duties as assigned.

Skills

Claims processing

Attention to detail

Microsoft Office

Analytical thinking

Education

High school diploma or equivalent

Tools

Claims processing software

Job description

Job Summary

The Recalculation Examiner is responsible for researching and reprocessing claims that were previously adjudicated and need to be reconsidered for all lines of business. 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 Recalculation Examiner is responsible for researching and reprocessing claims that were previously adjudicated and need to be reconsidered for all lines of business. 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

• Researches and reprocesses claims. Includes working with various internal departments including customer service, pricing, provider services, medical management, enrollment, grievance and appeals and configuration departments.
• Researches corrected claims received by the processing teams which are submitted by providers. Verifies the validity of the corrected claim submission and make necessary changes. Redirects any claims necessary back to processing staff to finalize.
• Performs clerical duties associated with the processing and completion of inquiries including first level appeal letters to the provider, requests for the loading of information for providers, members or authorizations.
• Researches and responds to first level inquiry appeals received via paper mail.
• Determines amounts of overpayments and completes necessary paperwork to request refunds.
• Maintain inventory tracking log, performs regular follow-up of claims routed to other areas.
• Interfaces with various departments to reach a resolution on claim corrections, research/re-adjudication projects and potential system issues.
• Identify and communicate trends or problems identified during adjudication process.
• Accurately resolves most unique problems or situations without supervisor involvement.
• Contribute to the creation of a pleasant working environment with peers and other departments.
• Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.
• Perform other 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 claims processing procedures.
• Knowledge of claims processing manuals and health benefit booklets.
• Knowledge in the contracted managed care plan terms and rates for multiple lines of business.
• Successful completion of Health Care Sanctions background check.
• Proficient in Microsoft applications.
• Ability to perform basic mathematical calculations.
• Demonstrated learning agility.
• Knowledge of Network Authorization requirements.
• Highly attentive to detail.
• Possess strong oral and written communication skills.
• Ability to organize time effectively and set priorities to meet deadlines.

Education/Experience

• High school diploma or equivalent required.
• Three years related work experience in claims processing, data entry or medical billing. One year of claims processing experience within CommunityCare or another healthcare environment is 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