Claims Specialist

• Manage lower-level, non-complex, and non-problematic workers’ compensation claims within delegated limited authority
• Work under the direct supervision of a senior claims professional
• Receive workers’ compensation claims and confirm policy coverage and claim acknowledgment
• Determine claim validity and compensability
• Establish reserves and authorize payments within reserving authority limits
• Manage non-complex lost-time workers’ compensation claims under close supervision
• Communicate claim status with customers, claimants, and clients
• Adhere to client and carrier guidelines
• Participate in claims reviews as needed
• Assist other claims professionals with complex or problematic claims
• Complete additional projects and duties as assigned

• Independently adjudicate professional CMS-1500 claims using benefits, pricing, coding guidelines, and contract terms
• Apply CPT, HCPCS, ICD-10 coding, benefit plans, and contract language to determine claim outcomes, pricing, payments, and denials
• Review and resolve pending claims, edits, denials, adjustments, and reprocessing requests
• Analyze claim and line-level data to identify coding discrepancies, system configuration issues, policy misalignment, eligibility discrepancies, authorization requirements, and billing errors
• Coordinate benefits by reviewing member eligibility, other insurance information, and payer responsibility
• Review provider disputes, reconsiderations, and appeals and determine whether reprocessing or adjustment is warranted
• Apply reimbursement methodologies, fee schedules, and pricing logic
• Identify recurring claim-processing issues and escalate findings to leadership
• Communicate with internal teams and providers to clarify claim details and resolve processing issues
• Maintain HIPAA and PHI confidentiality and security
• Follow claim routing, inventory control, and workflow procedures
• Participate in ongoing training and continuing education
• Meet productivity, quality, turnaround-time, attendance, and production standards
• Take direction from Department leadership and perform other duties as assigned
• No on-call or supervisory responsibilities

Certified Claims Processor I

• Review and evaluate CVC applications and supporting documentation to determine eligibility under Oregon statutes and administrative rules
• Interpret and apply Oregon Revised Statutes Chapter 147, Oregon Administrative Rules, and the Oregon Criminal Code
• Manage approximately 2,000 active claims annually throughout their life cycle
• Communicate with applicants, medical providers, law enforcement, advocates, and community partners by phone and email
• Compose administrative orders, requests for information, and inquiry responses
• Evaluate reconsideration requests and respond to applicants
• Assist with preparation and defense of claims appealed to the Workers’ Compensation Board, including testifying when necessary
• Authorize payments of up to $47,000 per claim for eligible crime-related expenses
• Evaluate medical documentation, treatment costs, chart notes, and treatment plans
• Explain application decisions, services, program processes, funding limits, and compensation requests
• Provide documentation and testify at restitution hearings virtually or in person
• Rotate as Examiner of the Day and provide coverage for other examiners and claims specialists
• Provide administrative support and training to staff, claims examiners, and service providers
• Perform other duties as assigned

Claims Specialist jobs in Oregon

Claims Specialist

Certified Claims Processor I

Claims Examiner – Crime Victim and Survivor Services Division