Claims Examiner II

CareOregon

Claims Examiner II responsible for the timely review and adjudication of Medicaid, Medicare, group and individual health claims for CareOregon. Ensuring compliance and meeting quality standards.

Posted 7/2/2026full-timeRemote • Oregon • 🇺🇸 United StatesJuniorMid-Level💰 $23 - $28 per hourWebsite

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

Minimum 2 years’ experience as a Medical Claims Examiner or other role that requires knowledge of medical coding and terminology (e.g., medical billing, prior authorizations, appeals and grievances, health insurance customer service, etc.)
Preferred 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 that relate to medical, dental, mental health and health insurance industry and Medicaid/Medicare industry
Ability to perform fast and accurate data entry
Basic computer skills (ability to use Microsoft Outlook, Word and Excel) and learn new systems as needed
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, and evaluate information and determine appropriate actions
Ability to accept direction and feedback, as well as tolerate and manage stress
Ability to see, read, hear, speak, and perform repetitive finger and wrist movement for at least 6 hours/day
Ability to lift, carry, reach, and/or pinch small objects for at least 1-3 hours/day

Benefits

Comp & perks

Health insurance
Dental insurance
Vision insurance
Life insurance
AD&D insurance
Disability insurance
Health savings account
Flexible spending account(s)
Lifestyle spending account
Employee assistance program
Wellness program
Discounts
Multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings)
Strong retirement plan with employer contributions
PTO and Paid State Sick Time based on hours worked/scheduled hours

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Medical CodingData EntryClaims AdjudicationEligibility DeterminationRefund ProcessingQuality ImprovementRegulatory ComplianceClaims AdjustmentThird Party InvestigationDocumentation Generation

Soft Skills

Detail OrientationOrganizational SkillsTime Management SkillsAbility to Work Under StressEffective Communication