Claims Examiner II (24206)

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.

Position Title: Claims Examiner II

Department: Claims and Member Services

Title of Manager: Claims Supervisor

Supervises: Non-supervisory position

Employment Status: Regular - Non-Exempt

Pay and Benefits: Pay and Benefits: Estimated hiring range $45,850 - $55,500/year, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits.

Posting Notes: This is a fully remote role, but you must live in one of the listed 9 states.

General Statement of Duties

Intermediate position responsible for the timely review, investigation, and adjudication of all types of Medicaid, Medicare, Group or Individual medical, dental, & mental health claims. Must meet or exceed quality and production standards.

Essential Position Functions

• Appropriately and correctly adjudicate medical, dental and mental health claims, and/or may re-adjudicate or adjust/correct, claims including some complex and difficult 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 based on Department and Company standards

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

• Collaborates with others inside and outside department to achieve business plan/goals

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

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

• May review and process refunds which may result in posting refunds and claim adjustments or re-adjudication.

• Utilize claims payment system to effectively adjudicate medical claims, or may re-adjudicate or adjust/correct medical claims, and generate letters and other documents as needed

• Proactively identify ways to improve quality and productivity

• Demonstrate initiative in seeking and understanding needed information about policies and procedures

• May make calls to providers to gather additional information to adjudicate claims timely and effectively

Essential Department and Organizational Functions

• Report to work as scheduled

• Perform other duties and projects as assigned

Knowledge, skills and abilities required

• High speed data enter with proven quality results

• Basic computer skills

• Knowledge of CPT, HCPCS, Revenue, DPT and ICD-9 coding.

• Knowledge of medical, dental, mental health and health insurance terminology.

• Good customer service skills

• Strong analytical and sound problem solving skills

• Understanding of State/Federal laws and other regulatory agency requirements that relate to the medical, dental, mental health and health insurance industry or Medicaid/Medicare industry

• Ability to type a minimum of 40 words per minute

• Detail orientation

• Strong written and oral communication skills

• Ability to work with diverse groups

• Ability to participate fully and constructively in meetings

• Strong organizational skills

• Good time management skills

• Ability to work in a fast-paced environment with multiple priorities

Physical Skills and Abilities

Lifting/Carrying up to 10 Pounds

Pushing/Pulling up to 0 Pounds

Pinching/Retrieving Small Objects

Crouching/Crawling

Reaching

Climbing Stairs

Repetitive Finger/Wrist/Elbow/

Shoulder/Neck Movement

1-3 hours/day

0 hours/day

1-3 hours/day

0 hours/day

1-3 hours/day

0 hours/day

More than 6 hours/day

Standing

Walking

Sitting

Bending

Seeing

Reading

Hearing

Speaking Clearly

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

Cognitive and Other Skills and Abilities

Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

Education and/or Experience

2 years or more as a medical claims processor in the health insurance industry, OR any work experience and/or training that would likely provide the ability to perform the essential functions of the position.

Working Conditions

• Environment: This position's primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):

☒ Inside/office ☐ Clinics/health facilities ☐ Member homes

☐ Other_________________________________________

• Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee's personal vehicle, local transit, or other means of transportation may be used.

• Equipment: General office equipment

• Hazards: n/a

#Li-Remote

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.

Veterans are strongly encouraged to apply.

We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.

Visa sponsorship is not available at this time.