Claims Examiner II

Position Title: Claims Examiner II Department: Claims and Member Services Title of Manager: Claims Supervisor Supervises: Non-supervisory position Employment Status: Regular – Non-Exempt Work Hours: Monday – Friday, 8:00 AM to 5:00 PM Requisition: 18004 General Statement of Duties Intermediate position responsible for the timely review, investigation, and adjudication of all types of Medicaid, Medicare, Group or Individual medical, dental, & mental health claims.

Must meet or exceed quality and production standards.

Essential Position Functions + Appropriately and correctly adjudicate medical, dental and mental health claims, and/or may re-adjudicate or adjust/correct, claims including some complex and difficult 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 + 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 or re-adjudication.

+ Utilize claims payment system to effectively adjudicate medical claims, or may re-adjudicate or adjust/correct medical claims, and generate letters and other documents as needed + Proactively identify ways to improve quality and productivity + Demonstrate initiative in seeking and understanding needed information about policies and procedures + May make calls to providers to gather additional information to adjudicate claims timely and effectively 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 enter with proven quality results + Basic computer skills + Knowledge of CPT, HCPCS, Revenue, DPT and ICD-9 coding.

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

+ Good customer service skills + Strong analytical and sound problem solving skills + 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 type a minimum of 40 words per minute + Detail orientation + Strong written and oral communication skills + Ability to work with diverse groups + Ability to participate fully and constructively in meetings + Strong organizational skills + Good time management skills + Ability to work in a fast-paced environment with multiple priorities Physical Skills and Abilities 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 2 years or more 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 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.

Equal opportunity employer.

This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

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