Claims Examiner II

🔥 4 minutes ago

🌲 Oregon – Remote

🌲 Oregon – Remote

💵 $23 - $28 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

📋 Claims Specialist

🚫👨‍🎓 No degree required

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CareOregon

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1994

⚕️ Healthcare Insurance

🤝 Non-profit

Healthcare Insurance • Non-profit

CareOregon is a community-focused health plan that provides coordinated physical, behavioral, dental and social-support services to Oregon Health Plan members, serving more than 500,000 people. The organization operates provider and member portals, offers care coordination, telehealth, language and tribal services, community grants and outreach, and programs addressing social determinants of health such as housing, nutrition and transportation.

📋 Description

• 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.

🎯 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