Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.
Position Title: Claims Examiner III
Exemption Status: Non-Exempt
Department: Claims and Member Services
Title of Manager: Claims Supervisor
Supervises: N/A
Requisition: 24305
Pay & Benefits:Estimated hiring range $51,800 - $63,320 / year, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits
Posting Notes: This is a fully remote position, but you must reside in one of the listed 9 states.
General Statement of Duties
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 Position Functions
- Appropriately and correctly evaluate complex and difficult medical, dental, and mental 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 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
- 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)
- 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/corrections or re-adjudication
- Utilize claims payment system to effectively adjudicate medical, dental, and mental 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
- Demonstrate initiative in seeking and understanding needed information about policies and procedures
- Proactively work to build and improve the team
- Independently manage special projects as assigned by the supervisor
- Act as a resource to the team
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 entry with proven quality results
- 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
- 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
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
Three years or more experience 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
#MULTI
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.