HMO Claims Adjudication Specialist

CommunityCare HMO Inc.; Tulsa (OK); Presencial; USD 38.000 - 52.000; Jornada completa

Descripción de la vacante

CommunityCare HMO Inc. in Tulsa, OK is seeking a Claims Examiner to review and adjudicate claims prior to adjudication.

You will determine actions to pay, deny or adjust based on resources, knowledge and careful decision-making to meet accuracy and efficiency targets. Applicants need a high school diploma and at least two years in claims processing or related medical billing, with strong communication, math skills, and proficiency in Microsoft tools.

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

Self-motivation

Reading medical terminology

Attention to detail

Communication skills

Microsoft applications

Basic math

Educación

High School Diploma or Equivalent

2 years related claims experience or medical billing education

Herramientas

Claims processing software

Descripción del empleo

CommunityCare HMO Inc. in Tulsa, OK is seeking a Claims Examiner to review and adjudicate claims prior to adjudication.

You will determine actions to pay, deny or adjust based on resources, knowledge and careful decision-making to meet accuracy and efficiency targets. Applicants need a high school diploma and at least two years in claims processing or related medical billing, with strong communication, math skills, and proficiency in Microsoft tools.