HMO Claims Examiner: Precision Adjudication & Analysis

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

Job summary

CommunityCare HMO Inc. in Oklahoma is seeking a Claims Examiner to review and adjudicate claims that require pre-payment review. You will use established guidelines, medical terminology, CPT codes, and processing software to determine when to pay, deny or adjust a claim.

The role emphasizes accuracy, efficiency, and collaboration with peers and other departments as you monitor trends, research complex cases, and ensure compliant, timely adjudication.

Qualifications

• High school diploma or equivalent required.
• Two years related work experience in claims processing, claims data entry or medical billing OR medical related education to meet minimum two years required.
• Ability to read and understand claims processing manuals, medical terminology, CPT codes, and perform basic processing procedures.
• 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.

Responsibilities

• 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.

Skills

Self-motivated

Claims processing

Medical terminology

CPT codes

Microsoft Office

Education

High School Diploma

Tools

Processing software

Job description

CommunityCare HMO Inc. in Oklahoma is seeking a Claims Examiner to review and adjudicate claims that require pre-payment review. You will use established guidelines, medical terminology, CPT codes, and processing software to determine when to pay, deny or adjust a claim.

The role emphasizes accuracy, efficiency, and collaboration with peers and other departments as you monitor trends, research complex cases, and ensure compliant, timely adjudication.