Claims Examiner II

The Claims Examiner II is responsible for reviewing, investigating, and adjudicating Medicaid, Medicare, and other health claims, ensuring compliance with regulations and policies. This role requires experience in medical claims processing and knowledge of coding systems, with a focus on accuracy, customer service, and continuous improvement.

Location: Work from home

Salary: $22.82 - $27.89

Responsibilities

• Adjudicate medical, dental and mental health claims in accordance and compliance 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 escalate 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.

Requirements

• 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.)

Benefits

• Strong Total Rewards Program including competitive pay, bonus opportunity, comprehensive benefits package, medical, dental, vision, life, AD&D, disability insurance, health savings account, flexible spending accounts, lifestyle spending account, employee assistance program, wellness program, discounts, supplemental benefits, retirement plan with employer contributions, PTO, Paid State Sick Time, paid holidays, volunteer time, jury duty, bereavement leave.