OPL Examiner I
Work from home Within Oregon, Washington, Idaho or Utah
Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.
Who We Are Looking For:
Every day, Cambia's dedicated OPL Examiner I, are living our mission to make healthcare easier and lives better. As a member of Claims Operations Team, our OPL Examiner I is responsible to review claims routed to Other Party Liability (OPL) department for possible third party investigation, under the direction of the supervisor and manager, to determine the Company's course of action on intentional and unintentional injury and occupational injury claims by initiating the investigation of potential first and third party liability. Responsible to, review, sort and triage returned incident reports and correspondence in light of information received and claims history, and to release claims that are not third-party liability. Responsible to code claim system and tracking systems promptly and accurately with steps and findings about investigations initiated or closed as review is completed. Responsible for providing specialized technical and cost-effective support in the investiga
tion to assure maximum third-party savings. Responsible to support workflow intake, tracking, and triage to ensure maximum workflow efficiency, accountability, and controls, all in service of creating a person-focused health care experience.
Do you have a passion for serving others and learning new things? Do you thrive as part of a collaborative, caring team? Then this role may be the perfect fit.
What You Bring to Cambia:
Qualifications:
* High school diploma or GED equivalent required.
* Minimum 2 years of related work experience, preferably in claims processing, or an equivalent combination of education and work experience.
Skills and Attributes:
* Excellent interpersonal skills with demonstrated basic knowledge of medical terminology, CPT and ICD-9 coding, and ability to type 30 wpm or 8,500 keystrokes per hour with 95% accuracy.
* Demonstrated 10-key skills, basic knowledge of claims systems and associated documents, and demonstrated understanding of OPL rules and regulations governed by contract exclusions is preferred.
* Ability to work with a high volume of claims and correspondence while keeping detailed and accurate records, combined with strong analytical ability.
* Demonstrated ability in organizational, problem-solving, and time-management skills with the ability to exercise initiative and independently make decisions within the scope of assigned authority while operating with minimum supervision.
* Ability to work as part of a team, demonstrate efficiency, meet established deadlines, triage and be flexible in evaluating competing priorities, and be responsive, available, and timely.
* Demonstrated proficient use of a PC and Windows software, including Microsoft Word and Excel.
* Facets experience or experience with claims systems used within Regence preferred, and experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.
What You Will Do at Cambia:
* Handles all claims pended as potential third-party liability, investigates initial need for further information relating to potential contract exclusions, and generates needed incident reports and correspondence for clarification surrounding third party information.
* Follows up on all pends received and investigates all claims determined to need further assessment.
* Sorts, reviews, triages, and further investigates returned incident reports, e-mails, and correspondence related to third-party claims for possible contract exclusion or subrogation action, then routes and handl
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