Career Opportunities: Claims Examiner III (24305) Requisition ID 24305 - Posted 06/14/2024 - CareOregon - Full Time - Permanent - Portland - Multi Location (17) 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 III Exemption Status: Non-Exempt Department: Claims and Member Services Title of Manager: Claims Supervisor Supervises: N/A Requisition: 24305 Pay & Benefits: Estimated hiring range $51,800 - $63,320 / year, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits Posting Notes: This is a fully remote position, but you must reside in one of the listed 9 states. General Statement of Duties Senior level position responsible for the timely review, investigation, and adjudication of all types of Medicaid, Medicare, Group or Individual medical, dental, & mental health claims. Act as a resource to other claims examiners, other departments, and management. Must meet or exceed quality and production standards. Essential Position Functions Appropriately and correctly evaluate complex and difficult medical, dental, and mental health claims which may result in adjudication, re-adjudication or adjustments of 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 Work collaboratively with other departments and OMAP to effectively provide customer service and the resolution of health plan problems (e.g., claims, eligibility, and system) 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/corrections or re-adjudication Utilize claims payment system to effectively adjudicate medical, dental, and mental health claims, or may re-adjudicate or adjustment claims, and generate letters and other documents as appropriate Assist the claims supervisor in mentoring new or existing claims examiners and identifying ways in which to improve quality and productivity and ways in which adjustments can be minimized May make calls to providers to gather additional information to adjudicate claims timely and effectively Assist claims examiners with claims processing and other questions Be an effective role model for other claims examiners and the department Demonstrate initiative in seeking and understanding needed information about policies and procedures Proactively work to build and improve the team Independently manage special projects as assigned by the supervisor Act as a resource to the team 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 entry with proven quality results In-depth knowledge of claims adjudication principles and procedures Advanced knowledge of CPT, HCPCS, Revenue, DPT and ICD-9 coding Strong knowledge of medical and health insurance t