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Adjustment Examiner I (Honolulu or Kapolei)


Posted: 10/2/2019
Job Reference #: 5000329069606
Categories: Other/General

Job Description

Employment Type


Exempt or Non-Exempt


Job Summary

Respond to customer inquiries regarding claim processing outcomes; identify and correct previous claim processing decisions; identify, analyze and document problems and causes of customer inquiries.

Minimum Qualifications

  1. Associates degree or 1 year of experience as an Adjustment Examiner Trainee or 2 years of experience as a benefits examiner or 2 years of experience in a position dealing with the public in a field related to healthcare or equivalent combination of education and experience .
  2. Strong oral and written communication skills.
  3. Critical thinking skills.
  4. Problem resolution skills.
  5. Good working knowledge of PC Desktop applications, to include Microsoft Word, Microsoft Excel, and Microsoft Outlook.


Duties and Responsibilities

  1. Review previously processed claims being questioned by a customer via public contact inquiries. Determine whether the automated and/or previous examiner decision is a correct payment policy outcome. Adjust the claim as appropriate.
  2. Respond in writing to public contact areas explaining any corrective action taken. Identify and communicate areas requiring member or provider education to the respective public contact area.
  3. Prepare cases for clinical review to include compiling supporting documentation and identifying issues and/or problems in writing to be reviewed and/or resolved by Medical Management staff.
  4. Review customer appeals and special handle projects and adjust the involved claims as appropriate. Communicate with the internal case coordinator verbally or in writing as necessary to clarify the processing request.
  5. Identify and perform routine analysis of the root causes for customer inquiries to be utilized in meeting corporate goals and/or service level agreements. Document and verbally present problems, recommend solutions, and/or corrective action for issues resulting in customer inquiries.
  6. Identify issues related to payment policy, QNXT system, and claims processing that resulted in payment errors. Research and document findings for problem report submission.
  7. Attend training, meetings, etc to expand business knowledge. Perform other duties as assigned.