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CareOregon · 1 hour ago

Claims Examiner II

United States

Full-time

Remote

Entry, Mid Level

$22.82/hr - $27.89/hr

2+ years exp

CareOregon is seeking a Claims Examiner II to be responsible for the timely review, investigation, and adjudication of various types of claims. The role involves ensuring compliance with regulations and providing excellent customer service while collaborating with other departments.

Health Care

Responsibilities

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

Perform work in alignment with the organization’s mission, vision and values

Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals

Strive to meet annual business goals in support of the organization’s strategic goals

Adhere to the organization’s policies, procedures and other relevant compliance needs

Perform other duties as needed

Qualification

Medical Claims ExaminationMedical Coding KnowledgeClaims AdjudicationQNXT ExperienceFacets ExperienceEpic Systems ExperienceCustomer Service SkillsAnalytical SkillsDetail OrientationCommunication SkillsOrganizational SkillsTime Management Skills

Required

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.)

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

Strong spoken and written communication skills

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

Preferred

Experience using QNXT, Facets, Epic systems

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