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Claims Examiner II

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Location: Portland OR

Company Name: CareOregon

Occupational Category: 13-1031.01,Claims Examiners, Property and Casualty Insurance

Date Posted: 2020-02-24

Valid Through: 2020-03-25

Employment Type: FULL_TIME


Position Title: Claims Examiner II

Department: Claims and Member Services

Title of Manager: Claims Supervisor

Supervises: Non-supervisory position

Employment Status: Regular – Non-Exempt

Work Hours: Monday – Friday, 8:00 AM to 5:00 PM

Requisition: 13049

General Statement of Duties

Intermediate position responsible for the timely review, investigation, and adjudication of all types of Medicaid, Medicare, Group or Individual medical, dental, & mental health claims. Must meet or exceed quality and production standards.

Essential Position Functions
• Appropriately and correctly adjudicate medical, dental and mental health claims, and/or may re-adjudicate or adjust/correct, claims including some complex and difficult 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
• 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 or re-adjudication.
• Utilize claims payment system to effectively adjudicate medical claims, or may re-adjudicate or adjust/correct medical claims, and generate letters and other documents as needed
• Proactively identify ways to improve quality and productivity
• Demonstrate initiative in seeking and understanding needed information about policies and procedures
• May make calls to providers to gather additional information to adjudicate claims timely and effectively

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 enter with proven quality results
• Basic computer skills
• Knowledge of CPT, HCPCS, Revenue, DPT and ICD-9 coding.
• Knowledge of medical, dental, mental health and health insurance terminology.
• Good customer service skills
• Strong analytical and sound problem solving skills
• Understanding of State/Federal laws and other regulatory agency requirements that relate to the medical, dental, mental health and health insurance industry or Medicaid/Medicare industry
• Ability to type a minimum of 40 words per minute
• Detail orientation
• Strong written and oral communication skills
• Ability to work with diverse groups
• Ability to participate fully and constructively in meetings
• Strong organizational skills
• Good time management skills
• Ability to work in a fast-paced environment with multiple priorities Physical Skills and Abilities

Lifting/Carrying up to 10 Pounds

Pushing/Pulling up to 0 Pounds

Pinching/Retrieving Small Objects



Climbing Stairs

Repetitive Finger/Wrist/Elbow/

Shoulder/Neck Movement

1-3 hours/day

0 hours/day

1-3 hours/day

0 hours/day

1-3 hours/day

0 hours/day

More than 6 hours/day








Speaking Clearly

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

Cognitive And Other Skills And Abilities

Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

Education And/or Experience

2 years or more as a medical claims processor in the health insurance industry, OR any work experience and/or training that would likely provide the ability to perform the essential functions of the position.

Working Conditions
• Environment: This position’s primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):
☒ Inside/office ☐ Clinics/health facilities ☐ Member homes

☐ Other_________________________________________
• Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.
• Equipment: General office equipment
• Hazards: n/a
Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

Veterans welcome to apply