CareOregon
Claims Examiner II
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.
Estimated Hiring Range $22.82 - $27.89
Bonus Target Bonus - SIP Target, 5% Annual
Essential Responsibilities
Adjudicate medical, dental and mental health claims in accordance 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 elevate 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.
Experience and/or Education
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: Indoor/Office (only). Member/Patient Facing: No.
Hazards: May include physical and ergonomic hazards. Equipment: General office equipment. Travel: May include occasional required or optional travel outside the workplace; 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.
Benefits We offer a strong Total Rewards Program, including competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as position type and scheduled weekly hours. Benefits‑eligible employees qualify for benefits beginning on the first of the month following 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.
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.
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Estimated Hiring Range $22.82 - $27.89
Bonus Target Bonus - SIP Target, 5% Annual
Essential Responsibilities
Adjudicate medical, dental and mental health claims in accordance 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 elevate 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.
Experience and/or Education
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: Indoor/Office (only). Member/Patient Facing: No.
Hazards: May include physical and ergonomic hazards. Equipment: General office equipment. Travel: May include occasional required or optional travel outside the workplace; 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.
Benefits We offer a strong Total Rewards Program, including competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as position type and scheduled weekly hours. Benefits‑eligible employees qualify for benefits beginning on the first of the month following 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.
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.
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