Claims Examiner II

The Claims Examiner II is an intermediate‑level position responsible for the timely review, investigation and adjudication of all types of Medicaid, Medicare, group and individual medical, dental, and mental health claims.

$22.82 – $27.89 per hour

Bonus – SIP Target, 5% annual

Current Care Oregon employees:
Please use the internal Workday site to submit an application for this job.

• Adjudicate medical, dental and mental health claims in accordance with plan provisions, state and federal regulations, and Care Oregon policies and procedures.
• Re‑adjudicate, adjust or correct claims, including complex and difficult claims as needed.
• Consistently meet or exceed the quality and production standards established by the department and Care Oregon.
• Provide excellent customer service to internal and external customers.
• Collaborate and share information with Claims teams and other Care Oregon departments to achieve excellent customer service and support organizational goals.
• Determine eligibility, benefit levels and coordination of benefits with other carriers; recognize and escalated 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 over payments, 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.

• Minimum 2 years’ experience as a Medical Claims Examiner or a role requiring knowledge of medical coding and terminology (e.g., medical billing, prior authorizations, appeals and grievances, health insurance customer service).

• Experience using QNXT, Facets, Epic systems.

• Knowledge of CPT, HCPCS, Revenue, CDT and ICD‑10 coding.
• Knowledge of medical, dental, mental health and health insurance terminology.

• Understanding of or ability to learn state and federal laws and other regulatory agency requirements related to medical, dental, mental health and health insurance industry and Medicaid/Medicare industry.
• Ability to perform fast and accurate data entry.
• Strong spoken and written communication skills.
• Basic computer skills (e.g., Microsoft Outlook, Word, Excel) and ability to learn new systems.
• Good customer service skills.
• Ability to participate fully and constructively in meetings.
• Strong analytical and sound problem‑solving skills.
• Detail orientation.
• Strong organizational skills and time‑management skills.
• Ability to work in a fast‑paced environment with multiple priorities.
• Ability to work effectively with diverse individuals and groups.
• Ability to learn, focus, understand, evaluate information and determine appropriate actions.
• Ability to accept direction and feedback, and tolerate/manage stress.
• Ability to perform repetitive finger and wrist movements for at least 6 hours per day.
• Ability to lift, carry, reach, and/or pinch small objects for at least 1‑3 hours per day.

Work Environment(s):
Indoor/Office.
Member/Patient Facing:
No.
Hazards:
Physical and ergonomic hazards may be present.
Equipment:
General office equipment.
Travel:
Occasional required or optional travel outside of the workplace; employee’s personal vehicle, local transit or other means may be used.

Work Location:

Work from home.

Schedule:

Monday – Friday, 8:00 AM to 5:00 PM.

We offer a strong Total Rewards Program, including competitive pay, bonus opportunity and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as position type and the number of scheduled weekly hours. Benefits‑eligible employees qualify for benefits beginning on the first of the month on or after their start date. Care Oregon offers medical, dental, vision, life, AD&D and disability insurance, a health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness…