HMO Claims Examiner: Precise Adjudication & Insights

CommunityCare, Inc.; Tulsa (OK); On-site; USD 35,000 - 55,000; Full time

Job summary

CommunityCare, Inc. is seeking a detail-oriented Claims Examiner to review and adjudicate claims prior to payment. You will determine payments, denials, or adjustments using standard guidelines and ensure accuracy and efficiency.

You will identify cases for escalation, input claim data, monitor trends, and support related teams. Strong CPT code knowledge and clear communication are essential.

Qualifications

• High School Diploma or Equivalent is required.
• Two years related work experience in claims processing or medical billing or a medical-related education.
• Knowledge of CPT codes and health benefit booklets.
• Ability to read claims processing manuals and perform basic processing procedures.
• Strong attention to detail and solid communication skills.

Responsibilities

• Examine and adjudicate claims that require review prior to adjudication.
• Enter claims information using processing software to compute payments, allowable amounts, limitations and denials.
• Identify claims needing additional resources and route to the appropriate person.
• Identify trends or issues during adjudication and communicate findings.
• Support team and other departments to maintain a positive work environment.
• Learn and adapt to changes related to claims processing and regulations.
• Perform other job-related duties as assigned.

Skills

Claims processing

Medical terminology

CPT codes

Attention to detail

Written communication

Microsoft Office

Education

High School Diploma or Equivalent

Two years related work experience in claims processing or medical billing

Tools

Microsoft Office

Job description

CommunityCare, Inc. is seeking a detail-oriented Claims Examiner to review and adjudicate claims prior to payment. You will determine payments, denials, or adjustments using standard guidelines and ensure accuracy and efficiency.

You will identify cases for escalation, input claim data, monitor trends, and support related teams. Strong CPT code knowledge and clear communication are essential.