CareOregon
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 per hour
Bonus Target Bonus – SIP Target, 5% annual
Current CareOregon employees: Please use the internal Workday site to submit an application for this job.
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 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 escalated 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.
Required Experience and/or Education
Minimum 2 years’ experience as a Medical Claims Examiner or a role requiring knowledge of medical coding and terminology (e.g., medical billing, prior authorizations, appeals and grievances, health insurance customer service).
Preferred
Experience using QNXT, Facets, Epic systems.
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 related 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 (e.g., Microsoft Outlook, Word, Excel) and ability to learn new systems.
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, evaluate information and determine appropriate actions.
Ability to accept direction and feedback, and tolerate/manage stress.
Ability to perform repetitive finger and wrist movements for at least 6 hours per day.
Ability to lift, carry, reach, and/or pinch small objects for at least 1‑3 hours per day.
Working Conditions Work Environment(s): Indoor/Office. Member/Patient Facing: No. Hazards: Physical and ergonomic hazards may be present. Equipment: General office equipment. Travel: Occasional required or optional travel outside of the workplace; employee’s personal vehicle, local transit or other means may be used. Work Location: Work from home. Schedule: Monday – Friday, 8:00 AM to 5:00 PM.
Total Rewards Program 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 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, a 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). 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 per hour
Bonus Target Bonus – SIP Target, 5% annual
Current CareOregon employees: Please use the internal Workday site to submit an application for this job.
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 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 escalated 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.
Required Experience and/or Education
Minimum 2 years’ experience as a Medical Claims Examiner or a role requiring knowledge of medical coding and terminology (e.g., medical billing, prior authorizations, appeals and grievances, health insurance customer service).
Preferred
Experience using QNXT, Facets, Epic systems.
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 related 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 (e.g., Microsoft Outlook, Word, Excel) and ability to learn new systems.
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, evaluate information and determine appropriate actions.
Ability to accept direction and feedback, and tolerate/manage stress.
Ability to perform repetitive finger and wrist movements for at least 6 hours per day.
Ability to lift, carry, reach, and/or pinch small objects for at least 1‑3 hours per day.
Working Conditions Work Environment(s): Indoor/Office. Member/Patient Facing: No. Hazards: Physical and ergonomic hazards may be present. Equipment: General office equipment. Travel: Occasional required or optional travel outside of the workplace; employee’s personal vehicle, local transit or other means may be used. Work Location: Work from home. Schedule: Monday – Friday, 8:00 AM to 5:00 PM.
Total Rewards Program 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 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, a 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). 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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