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Career Opportunities: Claims Examiner II (24206) Requisition ID 24206 - Posted 07/01/2024 - CareOregon - Full Time - Permanent - Portland - Multi Location (16) Job Description Print Preview Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin. Position Title: Claims Examiner II Department: Claims and Member Services Title of Manager: Claims Supervisor Supervises: Non-supervisory position Employment Status: Regular - Non-Exempt Pay and Benefits: Pay and Benefits: Estimated hiring range $45,850 - $55,500/year, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits. Posting Notes: This is a fully remote role, but you must live in one of the listed 9 states. 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 <