Claims Examiner III

The Claims Examiner III is a senior level position responsible for the timely review, investigation, and adjudication of all types of Medicaid, Medicare, Group or Individual medical, dental, & mental health claims. Act as a resource to other claims examiners, other departments, and management. Must meet or exceed quality and production standards.

Estimated Hiring Range

$25.42 - $31.07

Bonus Target

Bonus - SIP Target, 5% Annual

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

Job Summary

The Claims Examiner III is a senior level position responsible for the timely review, investigation, and adjudication of all types of Medicaid, Medicare, Group or Individual medical, dental, & mental health claims. Act as a resource to other claims examiners, other departments, and management. Must meet or exceed quality and production standards.

Essential Responsibilities

• Evaluate complex and difficult medical, dental, and behavioral health claims 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.
• Collaborates and share information with Claims teams and other CareOregon departments to achieve excellent customer service and support organizational goals.
• Consistently meet or exceed Department and Company policies including but not limited to quality, production, attendance, conduct.
• Work collaboratively with other departments and OMAP to effectively provide customer service and the resolution of health plan problems (e.g., claims, eligibility, and system).
• Determination eligibility, benefit levels, coordination of benefits with other carriers, recognize and escalate complex issues to the Lead or Supervisor as needed.
• May review, process and post refunds and claim adjustments or re-adjudications as needed.
• Utilize claims payment system to effectively adjudicate medical, dental, and behavioral health claims, or may re-adjudicate or adjustment claims, and generate letters and other documents as appropriate.
• Assist the claims supervisor in mentoring new or existing claims examiners and identifying ways in which to improve quality and productivity and ways in which adjustments can be minimized.
• May make calls to providers to gather additional information to adjudicate claims timely and effectively.
• Assist claims examiners with claims processing and other questions.
• Be an effective role model for other claims examiners and the department.
• 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.
• Act as a resource to the team.
  
  

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 3 years’ experience as a Medical Claims Examiner in the health insurance industry, or equivalent 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

• In-depth knowledge of claims adjudication principles and procedures
• Advanced knowledge of CPT, HCPCS, Revenue, DPT and ICD-9 coding
• Strong knowledge of medical and health insurance terminology
• Knowledge, including completion requirements, of CMS and UB-92 claim forms
• Strong 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
  
  

Skills And Abilities

• Ability to proactively identify ways to improve quality and productivity
• Ability to take the initiative to see beyond the original request so that all logically related work is completed without needing a specific request for implied steps
• Strong analytical and sound problem-solving skills
• Strong computer skills
• Strong written and oral communication skills
• Strong interpersonal skills
• Strong customer service skills
• Ability to type a minimum of 40 words per minute
• Detail orientation
• Ability to participate fully and constructively in meetings
• Strong organizational skills
• Good time management skills
• Ability to work in a fast-paced environment
• Ability to work with diverse groups
• Report to work as scheduled
• Perform other duties and projects as assigned
• High speed data entry with proven quality results
• 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
  
  

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

We are an equal opportunity employer

CareOregon is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.