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Adjustment Examiner II (Honolulu or Kapolei)


Posted: 10/2/2019
Job Reference #: 5000329077106
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. Research and resolve complex customer issues regarding benefit application and claims processing. Assist unit trainer(s) with quality assurance audits and on the job training.

Minimum Qualifications

  1. Associates degree or 2 years of experience as an Adjustment Examiner or 3 years of experience as a benefits examiner or 3 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. Excellent working knowledge of medical terminology, CMS 1500, UB92 claim forms, CPT-4, HCPCS, ICD-9 codes, and the processing system and all related databases and tools to readjudicate claims appropriately.
  6. Excellent working knowledge of PC Desktop applications, to include Microsoft Word, Microsoft Excel, and Microsoft Outlook.


Duties and Responsibilities

  1. Review previously processed complex 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. Review customer appeals, special handle projects, and complex customer issues. Adjust the involved claims as appropriate. Communicate with the case coordinator and/or management verbally or in writing as necessary to resolve the case. Document and verbally present problems, recommend solutions, and/or corrective action for issues resulting in customer inquiries.

  4. Identify, perform analysis, and track trends of the root causes and timeliness issues for customer inquiries and recommend solutions to be utilized in meeting corporate goals and/or service level agreements. Prepare complex 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.

  5. Assist QA trainer with on the job coaching and auditing of Adjustment Examiner trainees or Adjustment Examiner I. Represent the unit in inter- and intra-departmental meetings regarding unit functions.

  6. QA- Document the issue clearly and concisely using the Issue Team Track Request template, including screenprints and links to references.
  7. Other duties as assigned.