Making health care work for everyone.
Claims Examiner II
Location
Oregon
Posted
5 days ago
Salary
$23 - $28 / hour
Seniority
Mid Level
Job Description
Claims Examiner II
CareOregon
• Adjudicate medical, dental and mental health claims in accordance and compliance with plan provisions, state and federal regulations, and CareOregon policies and procedures. • Re-adjudicate, adjust or correct claims, including some complex and difficult claims as needed. • Consistently meet or exceed the quality and production standards established by the department and CareOregon. • Provide excellent customer service to internal and external customers. • Collaborate and share information with Claims teams and other CareOregon departments to achieve excellent customer service and support organizational goals. • Determine eligibility, benefit levels and coordination of benefits with other carriers; recognize and escalate complex issues to the Lead or Supervisor as needed. • Investigate third party issues as directed. • May review, process and post refunds and claim adjustments or re-adjudications as needed. • Report any overpayments, underpayments or other possible irregularities to the Lead or Supervisor as appropriate. • Generate letters and other documents as needed. • Proactively identify ways to improve quality and productivity. • Continuously learn and stay up to date with changing processes, procedures and policies.
Job Requirements
- Minimum 2 years’ experience as a Medical Claims Examiner or other role that requires knowledge of medical coding and terminology (e.g., medical billing, prior authorizations, appeals and grievances, health insurance customer service, etc.)
- Preferred Experience using QNXT, Facets, Epic systems
- Knowledge of CPT, HCPCS, Revenue, CDT and ICD-10 coding
- Knowledge of medical, dental, mental health and health insurance terminology
- Understanding of or ability to learn state and federal laws and other regulatory agency requirements that relate to medical, dental, mental health and health insurance industry and Medicaid/Medicare industry
- Ability to perform fast and accurate data entry
- Basic computer skills (ability to use Microsoft Outlook, Word and Excel) and learn new systems as needed
- Good customer service skills
- Ability to participate fully and constructively in meetings
- Strong analytical and sound problem-solving skills
- Detail orientation
- Strong organizational skills and time management skills
- Ability to work in a fast-paced environment with multiple priorities
- Ability to work effectively with diverse individuals and groups
- Ability to learn, focus, understand, and evaluate information and determine appropriate actions
- Ability to accept direction and feedback, as well as tolerate and manage stress
- Ability to see, read, hear, speak, and perform repetitive finger and wrist movement for at least 6 hours/day
- Ability to lift, carry, reach, and/or pinch small objects for at least 1-3 hours/day
Benefits
- Health insurance
- Dental insurance
- Vision insurance
- Life insurance
- AD&D insurance
- Disability insurance
- Health savings account
- Flexible spending account(s)
- Lifestyle spending account
- Employee assistance program
- Wellness program
- Discounts
- Multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings)
- Strong retirement plan with employer contributions
- PTO and Paid State Sick Time based on hours worked/scheduled hours
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