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CareOregon · 3 hours ago

Claims Examiner Lead

United States

Full-time

Remote

Mid, Senior Level

$25.42/hr - $31.07/hr

3+ years exp

CareOregon is a healthcare organization that is seeking a Claims Examiner Lead to manage the daily operations of the Claims Examiner team. This role involves overseeing work distribution, performance tracking, and providing technical assistance, while also ensuring compliance with claims processing standards and training team members.

Health Care

Responsibilities

Evaluate complex and difficult medical, dental, and behavioral health claim which may result in adjudication, re-adjudication or adjustments of claims in accordance and/or compliance with plan provisions, State/Federal regulations, and CareOregon policies/procedures

Provide excellent customer service to internal and external customers

Utilize CareOregon on-line phone tracking system to document all activities from any mode of communication as defined by CareOregon and Claim Department policies

Consistently meet or exceed Department and Company policies including but not limited to quality, production, attendance, conduct

Determination eligibility, benefit levels, coordination of benefits with other carriers, recognize and investigate third party issues which may require working with attorneys or outside agents

Assist the claims supervisor in mentoring new or existing claims examiners which includes auditing employee work, identifying ways in which quality and productivity can be improved, and adjustments can be minimized

Assist claims examiners with claims processing and other questions

Continuously learn and stay up to date with changing processes, procedures and policies

Proactively work to build and improve the team

Independently manage special projects as assigned by the supervisor

Identify trends and communicate findings and process improvement ideas to the supervisor

Work collaboratively with other CareOregon departments to ensure timely, accurate, and effective claims adjudication

May develop reference documentation for department use

Provide training to new employees on specific tasks related to their job responsibilities

Coordinate with departments and external vendors to ensure all aspects of the projects have been appropriately addressed

Provide leadership for a team in support of team direction and goals

Provide input into staffing needs; assist in recruiting and hiring staff, using an equity, diversity, and inclusion lens

Participate in organizing, scheduling, monitoring and improving work; help ensure employees have information to meet job expectations and have coverage during absences

Contribute to the development, communication, and oversight of team and individual goals

Train, lead, and coach employees; may facilitate team meetings

Incorporate guidance from CareOregon equity tools into people leadership

Help monitor employee adherence to department and organizational standards, policies, and procedures

Assist in evaluating employee performance, providing feedback to support success, recognizing strong performance, and addressing performance gaps and accountability (corrective action)

Perform lead tasks in collaboration with Human Resources as needed

Qualification

Claims adjudicationCPT codingICD-9 codingCustomer serviceProject leadershipAnalytical skillsCommunication skillsInterpersonal skillsOrganizational skillsTime management

Required

Minimum 3 years' experience as a medical claims processor in the health insurance industry

In-depth knowledge of claims adjudication principles and procedures

Advanced knowledge of CPT, HCPCS, Revenue, DPT and ICD-9 coding

Strong knowledge of medical, dental, mental health and health insurance terminology

Knowledge, including completion requirements, of CMS and UB-92 claim forms

Strong understanding of federal and state laws and other regulatory agency requirements that relate to the medical, dental, mental health and health insurance industry or Medicaid/Medicare industry

Ability to proactively identify and work to improve the team's quality and productivity

Ability to take the initiative to see beyond the original request and complete appropriate next steps

Ability to use strong analytical and critical thinking skills in solving problems

Ability to work well under pressure in a complex and rapidly changing environment

Strong written and oral communication skills

Excellent interpersonal skills

Excellent customer service skills

Strong organizational and time management skills

Ability to effectively manage multiple tasks and to remain flexible in a dynamic work environment

Strong multidisciplinary collaborative skills

Ability to be a positive and influential role model for other department members

Ability to assess training needs and may organize and conduct training sessions

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, and perform repetitive finger and wrist movement for at least 6 hours/day

Ability to hear and speak clearly for at least 3-6 hours/day

Preferred

Experience with people and/or project leadership

Benefits

Medical, dental, vision, life, AD&D, and 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, etc.)

Strong retirement plan with employer contributions

PTO and Paid State Sick Time

Paid holidays

Volunteer time

Jury duty

Bereavement leave