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CommUnityCare
CommUnityCare

60 Communitycare Jobs Hiring Near You

CommUnityCare

Registered Dental Hygienist

Austin, TX · On-site

$39.75 - $49.75/hr

... CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures. * Develop and maintain favorable internal relationships, partnerships with co‑workers, including clinical ...

CommUnityCare

Advanced Practice Provider

Austin, TX · On-site

... CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures. • Develop and maintain favorable internal relationships, partnerships with co-workers, including clinical ...

CommUnityCare

Registered Dental Hygienist

Del Valle, TX · On-site

$44.25 - $55.50/hr

... CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures. • Develop and maintain favorable internal relationships, partnerships with co-workers, including clinical ...

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Infographic showing various job openings at Communitycare in the United States as of September 2026, with employment types broken down into 5% As Needed, 81% Full Time, 13% Part Time, and 1% Temporary. Highlights an 91% Physical, 4% Hybrid, and 5% Remote job distribution.

Claims HMO - Recalculation Examiner 140-1036

Tulsa, OK • On-site

CommunityCare
See more jobs at CommunityCareexternal

Full-time

Posted 26 days ago

Key responsibilities

  • Researches and reprocesses claims, working with various internal departments to determine appropriate actions for payment, denial, or adjustment.

  • Researches corrected claims received from providers, verifies their validity, makes necessary changes, and redirects claims back to processing staff if needed.

  • Responds to first level inquiry appeals received via paper mail and performs clerical duties related to claim inquiries and appeals.

Job description

JOB SUMMARY:
The Recalculation Examiner is responsible for researching and reprocessing claims that were previously adjudicated and need to be reconsidered for all lines of business. The examiner will use their resources, knowledge and decision-making acumen to determine the appropriate actions to pay, deny or adjust the claim. Examiners are expected to meet performance expectations in accuracy and efficiency.
KEY RESPONSIBILITIES:
  • Researches and reprocesses claims. Includes working with various internal departments including customer service, pricing, provider services, medical management, enrollment, grievance and appeals and configuration departments.
  • Researches corrected claims received by the processing teams which are submitted by providers. Verifies the validity of the corrected claim submission and make necessary changes. Redirects any claims necessary back to processing staff to finalize.
  • Performs clerical duties associated with the processing and completion of inquiries including first level appeal letters to the provider, requests for the loading of information for providers, members or authorizations.
  • Researches and responds to first level inquiry appeals received via paper mail.
  • Determines amounts of overpayments and completes necessary paperwork to request refunds.
  • Maintain inventory tracking log, performs regular follow-up of claims routed to other areas.
  • Interfaces with various departments to reach a resolution on claim corrections, research/re-adjudication projects and potential system issues.
  • Identify and communicate trends or problems identified during adjudication process.
  • Accurately resolves most unique problems or situations without supervisor involvement.
  • Contribute to the creation of a pleasant working environment with peers and other departments.
  • Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.
  • Perform other duties as assigned.

QUALIFICATIONS:
  • Self-motivated and able to work with minimal direction.
  • Ability to read and understand claims processing manuals, medical terminology, CPT codes and perform claims processing procedures.
  • Knowledge of claims processing manuals and health benefit booklets.
  • Knowledge in the contracted managed care plan terms and rates for multiple lines of business.
  • Successful completion of Health Care Sanctions background check.
  • Proficient in Microsoft applications.
  • Ability to perform basic mathematical calculations.
  • Demonstrated learning agility.
  • Knowledge of Network Authorization requirements.
  • Highly attentive to detail.
  • Possess strong oral and written communication skills.
  • Ability to organize time effectively and set priorities to meet deadlines.

EDUCATION/EXPERIENCE:
  • High school diploma or equivalent required.
  • Three years related work experience in claims processing, data entry or medical billing. One year of claims processing experience within CommunityCare or another healthcare environment is required.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin

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