Job Description:
• 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.)
• Preferred Experience using QNXT, Facets, Epic systems
• Knowledge of CPT, HCPCS, Revenue, CDT and ICD-10 coding
• Understanding of or ability to learn state and federal laws and other regulatory agency requirements that relate to medical, dental, mental health and health insurance industry and Medicaid/Medicare industry
• Ability to perform fast and accurate data entry
• Basic computer skills (ability to use Microsoft Outlook, Word and Excel) and learn new systems as needed
Benefits:
• medical, dental, vision, life, AD&D, and disability insurance
• health savings account
• flexible spending account(s)
• lifestyle spending account
• employee assistance program
• wellness program
• discounts
• multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings)
• strong retirement plan with employer contributions
• PTO and Paid State Sick Time based on hours worked/scheduled hours
• paid holidays
• volunteer time
• jury duty
• bereavement leave