Senior Medical Claims Examiner — Complex HMO Claims

CommunityCare, Inc.; Tulsa (OK); On-site; USD 52,000 - 76,000; Full time

Job summary

CommunityCare, Inc. in Tulsa, OK is seeking a Senior Claims Examiner to review and adjudicate complex claims requiring analysis prior to payment. You will apply benefit provisions, guidelines, and processing rules to determine outcomes with accuracy and efficiency.

You will handle high-complexity claims across multiple lines of business and may take on training responsibilities for junior Examiners while staying current with regulatory requirements and methodologies.

Qualifications

• Two or more years of medical claims processing experience.
• Ability to interpret claims processing manuals and CPT codes.
• Knowledge of health benefit booklets and processing guidelines.
• Demonstrated learning agility and ability to adapt to changing requirements.
• Proficiency with Microsoft Office applications.

Responsibilities

• Examine and adjudicate complex or specialized claims across multiple lines of business.
• Enter and validate claim information to determine payments, limits, exclusions, and denials.
• Identify trends, processing issues, or recurring problems observed during adjudication.
• Resolve complex claims independently and escalate when appropriate.
• Maintain knowledge of changes to processing procedures and guidelines and adapt processes accordingly.

Skills

Independent work

Claims processing knowledge

Interpreting CPT codes

Attention to detail

Strong communication

Education

High School Diploma or Equivalent

Tools

Microsoft Office

Job description

CommunityCare, Inc. in Tulsa, OK is seeking a Senior Claims Examiner to review and adjudicate complex claims requiring analysis prior to payment. You will apply benefit provisions, guidelines, and processing rules to determine outcomes with accuracy and efficiency.

You will handle high-complexity claims across multiple lines of business and may take on training responsibilities for junior Examiners while staying current with regulatory requirements and methodologies.