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Claims HMO - Claims Examiner 140-1031
Claims HMO - Claims Examiner 140-1031CommunityCare • Tulsa, OK, US
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Claims HMO - Claims Examiner 140-1031

Claims HMO - Claims Examiner 140-1031

CommunityCare • Tulsa, OK, US
[job_card.30_days_ago]
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  • [job_card.full_time]
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Claims Examiner

The Claims Examiner is responsible for examining claims that require review prior to being adjudicated. The examiner will use their resources, knowledge and decision-making acumen to determine the appropriate actions to pay, deny or adjust the claim. Examiners are expected to meet performance expectations in accuracy and efficiency.

Key responsibilities include:

  • Examining and adjudicating claims that have pended for review utilizing resources, tools, knowledge and decision-making in determining appropriate actions.
  • Identifying claims requiring additional resources and routing to the team lead, supervisor or other departments as needed.
  • Entering claims information using the processing software to compute payments, allowable amounts, limitations, exclusions and denials.
  • Identifying and communicating trends or problems identified during the adjudication process.
  • Contributing to the creation of a pleasant working environment with peers and other departments.
  • Assisting in investigating and solving claims that require additional research.
  • Consistently learning and adapting to changes related to claims processing, benefits, limits and regulations.
  • Performing other duties as assigned.

Qualifications:

  • Self-motivated and able to work with minimal direction.
  • Ability to read and understand claims processing manuals, medical terminology, CPT codes, and perform basic processing procedures.
  • Ability to read and understand health benefit booklets.
  • 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.

Education/Experience:

  • 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.
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Claims HMO - Claims Examiner 140-1031 • Tulsa, OK, US

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