HMO Claims Recalculation Specialist

CommunityCare, Inc.; Tulsa, Northern (OK, KY); Hybrid; USD 42,000 - 64,000; Full time

Job summary

CommunityCare, Inc. in Tulsa, OK is seeking a Recalculation Examiner to research and reprocess previously adjudicated claims across all lines of business.

You will apply your knowledge to determine actions to pay, deny, or adjust claims, while meeting accuracy and efficiency targets. This role collaborates with customer service, pricing, provider services, medical management, enrollment, grievance and appeals, and configuration teams.

Qualifications

• High school diploma or equivalent.
• Three years related work experience in claims processing, data entry or medical billing.
• One year of claims processing experience within CommunityCare or another healthcare environment.
• Ability to read and understand claims processing manuals and CPT codes.
• Proficiency in Microsoft applications.
• Strong attention to detail and communication skills.

Responsibilities

• Researches and reprocesses claims with various internal departments.
• Verifies corrected claim submissions and routes changes to processing staff.
• Performs clerical duties related to inquiries and first level appeal letters.
• Responds to first level inquiry appeals received via paper mail.
• Determines overpayments and processes refund paperwork.
• Maintains inventory tracking log and follows up on routed claims.
• Interfaces with departments to resolve adjudication issues.
• Identifies trends or problems in the adjudication process.
• Contributes to a pleasant working environment and adapts to changes.

Skills

Self-motivation

Claims processing knowledge

CPT codes familiarity

Microsoft Office

Attention to detail

Time management

Written and verbal communication

Education

High school diploma or equivalent

Tools

Microsoft Office

Job description

CommunityCare, Inc. in Tulsa, OK is seeking a Recalculation Examiner to research and reprocess previously adjudicated claims across all lines of business.

You will apply your knowledge to determine actions to pay, deny, or adjust claims, while meeting accuracy and efficiency targets. This role collaborates with customer service, pricing, provider services, medical management, enrollment, grievance and appeals, and configuration teams.