Job Posting: Claims Examiner II

Company: Cow Creek Band of The Umpqua Tribe of Indians

Job Description:

The Cow Creek Band of the Umpqua Tribe of Indians is excited to announce an opportunity to join our team as a Claims Examiner II. This is a Full-Time, non-remote position based in our Benefits Administration department. As a Claims Examiner II, you will play a crucial role in ensuring the accuracy, efficiency, and integrity of our claims handling processes. This position demands a high level of dedication and proficiency in claims management, along with a strong commitment to upholding the values and responsibilities entrusted to our team.

The ideal candidate will be responsible for claims production and overseeing the accurate and timely adjudication of claims in accordance with plan benefits and maintaining established production and quality standards. This role is integral to ensuring that our claims handling processes align with the Tribe’s objectives for exceptional service delivery and operational excellence.

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 of 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:

• 3-5 years of medical claims processing experience.
• Knowledge of Medical Terminology and health benefits required.
• Good analytical, problem-solving, and decision-making skills.
• Excellent verbal and written communication skills including active listening.
• Proficient computer skills with the capability to learn new software.
• Organized with attention to detail.
• Ability to multi-task and work independently with minimal supervision.
• High school diploma or equivalent.