HMO Claims Adjudicator: Precise Benefit Decisions

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

Job summary

CommunityCare, Inc. seeks a Claims Examiner to review and adjudicate pended claims before payment. You will use manuals, CPT codes, and health benefit knowledge to determine actions and ensure accuracy in processing.

Responsibilities include routing complex claims, entering data into processing software, identifying trends, and supporting a collaborative team environment while staying current with changes in regulations and benefit terminology.

Qualifications

• Requires self-motivation and ability to work with minimal direction.
• Ability to read claims processing manuals, CPT codes, and medical terminology.
• Ability to read health benefit booklets.
• Demonstrated learning agility.
• Health care sanctions background check required.
• Knowledge of contracted managed care plan terms and rates.
• Understanding of unbundling methods, COB, and over-billing.

Responsibilities

• Review and adjudicate pended claims prior to adjudication.
• Route complex claims to team lead or other departments as needed.
• Enter claims information into processing software to compute payments and denials.
• Identify trends or problems during adjudication.
• Contribute to 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

Claims processing

Attention to detail

Communication skills

Microsoft Office

Medical terminology

Math calculations

Education

High School Diploma

Job description

CommunityCare, Inc. seeks a Claims Examiner to review and adjudicate pended claims before payment. You will use manuals, CPT codes, and health benefit knowledge to determine actions and ensure accuracy in processing.

Responsibilities include routing complex claims, entering data into processing software, identifying trends, and supporting a collaborative team environment while staying current with changes in regulations and benefit terminology.