Medical Claims Examiner II

Job Description

Job Description

Job Posting : Medical Claims Examiner IICompany : Cow Creek Band of The Umpqua Tribe of IndiansJob Description

The Cow Creek Band of The Umpqua Tribe of Indians invites qualified individuals to apply for the position of Medical Claims Examiner II. This crucial role supports our mission to provide exceptional healthcare services by ensuring the accuracy and efficiency of our medical claims processing. As a Medical Claims Examiner II, you will be tasked with the oversight and execution of detailed claims examination, supporting both our team and the community we serve.

This full-time position is based in our main office and is not eligible for remote work. Candidates should be prepared to contribute to a dynamic team environment and uphold the highest standards of accuracy and efficiency in claims processing.

Duties and Responsibilities

• Claim auditing to ensure accuracy of claim processing
• Train level I claim examiners
• Customer service support
• Maintain resource materials with up-to-date information for claims and customer service staff
• Adjudicate electronic and manual claims for all lines of coverage (Medical, Dental, Vision) based on coverage benefits, coding guidelines, medical review determination, prior-authorization, and benefit limitations
• Advanced knowledge of CPT, HCPCS, ICD10, Revenue codes, CDT, etc.
• Ability to research and identify third party liability, coordination of benefits (COB) cases, and apply benefits accordingly as well as updating eligibility records
• Ability to understand and manually calculate all types of claims pricing (Medicare, Medicaid)
• Satisfy required quantity / quality claims processing requirements
• Ability to effectively communicate with members, providers, and other team members
• Maintain confidentiality and project a professional business presence and appearance
• Performs other related duties as assigned

Requirements