HMO Claims Recalculation Specialist

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

Job summary

CommunityCare HMO Inc. in Tulsa, OK is seeking a Recalculation Examiner to research and reprocess claims previously adjudicated.

The role requires evaluating provider submissions, processing corrections, and ensuring accurate pay/deny/adjust decisions with a focus on accuracy and efficiency. Typical responsibilities include handling first level appeal letters, refunds for overpayments, and coordinating with multiple departments to resolve issues while staying compliant with plan terms and

Qualifications

• Must be self-motivated with minimal direction.
• Ability to read claims processing manuals, understand CPT codes, and perform processing procedures.
• Knowledge of health benefit booklets and plan terms.
• Proficient in Microsoft Office and basic data entry.
• Strong attention to detail and written/oral communication skills.

Responsibilities

• Researches and reprocesses claims across multiple internal departments.
• Verifies corrected claim submissions and redirects to processing staff as needed.
• Performs clerical duties including first level appeal letters.
• Responds to first level inquiry appeals received by mail.
• Determines overpayments and completes refund paperwork.
• Maintains inventory tracking log and follows up on routed claims.
• Interfaces with departments to resolve corrections and system issues.
• Identifies trends or problems during adjudication.
• Resolves most unique problems without supervisor involvement.
• Contributes to a collaborative, pleasant work environment.
• Adapts to changes in claims processing, benefits, limits and regulations.
• Performs other duties as assigned.

Skills

Claims processing

Attention to detail

Microsoft Office

Analytical thinking

Education

High school diploma or equivalent

Tools

Claims processing software

Job description

CommunityCare HMO Inc. in Tulsa, OK is seeking a Recalculation Examiner to research and reprocess claims previously adjudicated.

The role requires evaluating provider submissions, processing corrections, and ensuring accurate pay/deny/adjust decisions with a focus on accuracy and efficiency. Typical responsibilities include handling first level appeal letters, refunds for overpayments, and coordinating with multiple departments to resolve issues while staying compliant with plan terms and