Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.
Job Title: Claims Examiner II
Exemption Status:Non-Exempt
Management Level:n/a
Direct Reports:n/a
Manager Title:Claims Supervisor
Department: Claims
Pay and Benefits:Estimated hiring range $22.38 - $27.35/hour, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits
Posting Notes:This is a fully remote role, but you must reside in one of the listed 9 states.
Job Summary
The Claims Examiner II is an intermediate level position responsible for the timely review, investigation and adjudication of all types of Medicaid, Medicare, group and individual medical, dental, and mental health claims.
Essential 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.
Organizational Responsibilities
- 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.
Experience and/or Education
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.)
Preferred
- Experience using QNXT, Facets, Epic systems
Knowledge, Skills and Abilities Required
Knowledge
- Knowledge of CPT, HCPCS, Revenue, CDT and ICD-10 coding
- Knowledge of medical, dental, mental health and health insurance terminology
Skills and Abilities
- 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
Working Conditions
Work Environment(s):
☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure
Member/Patient Facing:
☒ No ☐ Telephonic ☐ In Person
Hazards:May include, but not limited to, physical and ergonomic hazards.
Equipment: General office equipment
Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.
Work Location: Work from home
Schedule:Monday – Friday, 8:00 AM to 5:00 PM
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.
