Claims Recalculation Specialist – HMO

CommunityCare, Inc.; Tulsa, Northern (OK, KY); Hybrid; USD 40,000 - 60,000; Full time

Job summary

CommunityCare, Inc. in Tulsa, OK is seeking a Recalculation Examiner to research and reprocess adjudicated claims across all lines of business, deciding whether to pay, deny or adjust.

The role emphasizes accuracy, efficiency, and continuous learning in a fast-paced claims environment. You will collaborate with customer service, pricing, provider services and medical management, handle corrected submissions, respond to inquiries, and manage overpayments and refunds while maintaining proper logs

Qualifications

• High school diploma or equivalent required; three years related work experience in claims processing, data entry or medical billing; one year within CommunityCare or another healthcare environment is preferred.
• Experience with claims processing manuals, CPT codes and health benefit booklets is desirable.
• Knowledge of contracted managed care plan terms and rates for multiple lines of business.

Responsibilities

• Researches and reprocesses claims, coordinating with customer service, pricing, provider services, medical management, enrollment, grievance and appeals and configuration departments.
• Researches corrected claims submitted by providers; verifies validity and makes necessary changes; routes as needed to processing staff to finalize.
• Performs clerical duties related to processing and completing inquiries, including first level appeal letters to providers and information loading requests.
• Researches and responds to first level inquiry appeals received via paper mail.
• Determines amounts of overpayments and completes paperwork to request refunds.
• Maintains inventory tracking log and follows up on claims routed to other areas.
• Interfaces with departments to resolve claim corrections, re-adjudication projects, and system issues.
• Identifies and communicates trends or problems identified during adjudication.
• Resolves most unique problems or situations without supervisor involvement.
• Contributes to a pleasant working environment with peers and other departments.
• Continuously learns and adapts to changes related to claims processing, benefits, limits and regulations.
• Performs other duties as assigned.

Skills

Claims processing

Attention to detail

Time management

Communication skills

Mathematical calculations

Education

High school diploma or equivalent

Three years related work experience in claims processing

Tools

Microsoft applications

Data entry

Job description

CommunityCare, Inc. in Tulsa, OK is seeking a Recalculation Examiner to research and reprocess adjudicated claims across all lines of business, deciding whether to pay, deny or adjust.

The role emphasizes accuracy, efficiency, and continuous learning in a fast-paced claims environment. You will collaborate with customer service, pricing, provider services and medical management, handle corrected submissions, respond to inquiries, and manage overpayments and refunds while maintaining proper logs