Claims Recalculation Specialist

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 42,000 - 60,000; Full time

Job summary

CommunityCare HMO Inc. in Tulsa, OK seeks a Recalculation Examiner responsible for researching and reprocessing claims previously adjudicated to determine pay/deny/adjust actions.

You will collaborate with customer service, pricing, provider services and other teams, verify corrected submissions, handle inquiries, identify overpayments, and support ongoing claims processing improvements.

Qualifications

• Self-motivated and able to work with minimal direction.
• Ability to read and understand claims processing manuals, medical terminology, CPT codes.
• 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.

Responsibilities

• Researches and reprocesses claims, coordinating with customer service, pricing, provider services, medical management, enrollment, grievance and appeals, and configuration departments.
• Verifies corrected claim submissions and makes necessary changes; redirects claims to processing staff to finalize.
• Performs clerical duties related to inquiries, including first level appeal letters and requests for loading information for providers, members or authorizations.
• Responds to first level inquiry appeals received via paper mail.
• Determines amounts of overpayments and completes necessary paperwork to request refunds.
• Maintains inventory tracking log and follows up on claims routed to other areas.
• Interfaces with various departments to resolve claim corrections, re-adjudication projects and system issues.
• Identify and communicate trends or problems identified during adjudication process.
• Accurately resolves most unique problems or situations without supervisor involvement.
• Contributes to a pleasant working environment with peers and other departments.
• Continuously learn and adapt to changes related to claims processing, benefits, limits and regulations.
• Performs other duties as assigned.

Skills

Self-motivation

Claims processing knowledge

Microsoft Office

Strong communication

Attention to detail

Time management

Education

High school diploma or equivalent

Job description

CommunityCare HMO Inc. in Tulsa, OK seeks a Recalculation Examiner responsible for researching and reprocessing claims previously adjudicated to determine pay/deny/adjust actions.

You will collaborate with customer service, pricing, provider services and other teams, verify corrected submissions, handle inquiries, identify overpayments, and support ongoing claims processing improvements.