Claims Examiner II

This is a fully remote position, open to applicants in Oregon.

📋 Description

• Evaluate medical, dental, and mental health claims in compliance with plan provisions, state and federal regulations, as well as CareOregon policies and procedures.

• Reassess, modify, or rectify claims, including complex and challenging cases as necessary.

• Regularly achieve or surpass the quality and productivity benchmarks set by the department and CareOregon.

• Deliver exceptional customer service to both internal and external clients.

• Collaborate and exchange information with Claims teams and other departments within CareOregon to ensure outstanding customer service and support organizational objectives.

• Assess eligibility, benefit levels, and coordination of benefits with other insurers; identify and escalate complex matters to the Lead or Supervisor when required.

• Investigate third-party issues as directed.

• May review, process, and issue refunds and claim adjustments or re-adjudications as necessary.

• Notify the Lead or Supervisor of any overpayments, underpayments, or other potential discrepancies as appropriate.

• Create letters and additional documentation as required.

• Actively seek opportunities to enhance quality and productivity.

• Commit to ongoing learning and remain informed about evolving processes, procedures, and policies.

⛳️ Requirements

• At least 2 years of experience as a Medical Claims Examiner or in a similar position requiring knowledge of medical coding and terminology (e.g., medical billing, prior authorizations, appeals and grievances, health insurance customer service, etc.)

• Familiarity with QNXT, Facets, and Epic systems is preferred.

• Understanding of CPT, HCPCS, Revenue, CDT, and ICD-10 coding.

• Knowledge of medical, dental, mental health, and health insurance terminology.

• Comprehension of or willingness to learn about state and federal regulations and other regulatory requirements associated with the medical, dental, mental health, and health insurance industries, including Medicaid/Medicare.

• Capability to perform quick and precise data entry.

• Basic computer proficiency (ability to utilize Microsoft Outlook, Word, and Excel) and adaptability to new systems as necessary.

• Strong customer service abilities.

• Capacity to engage constructively in meetings.

• Excellent analytical and problem-solving skills.

• Attention to detail.

• Strong organizational and time management capabilities.

• Ability to thrive in a fast-paced environment with multiple priorities.

• Proficiency in working effectively with diverse individuals and groups.

• Capability to learn, concentrate, comprehend, and assess information to determine appropriate actions.

• Willingness to accept guidance and feedback, as well as manage stress effectively.

• Ability to see, read, hear, speak, and 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.

🏝️ Benefits

• Health insurance

• Dental insurance

• Vision insurance

• Life insurance

• AD&D insurance

• Disability insurance

• Health savings account

• Flexible spending account

• Lifestyle spending account

• Employee assistance program

• Wellness program

• Discounts

• Supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings)

• Retirement plan with employer contributions

• PTO and Paid State Sick Time