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Adjustment Examiner Trainee (Honolulu or Kapolei)
Exempt or Non-ExemptNon-exempt
Develop the ability to 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. An individual is expected to progress from the trainee position to Adjustment Examiner I.
- High School diploma or equivalent and 1 year of work experience in a position dealing with the public; or 1 year of work experience as a benefits examiner or equivalent combination of education and experience.
- Strong oral and written communication skills.
- Basic knowledge of PC Desktop applications, to include Microsoft Word, Microsoft Excel, and Microsoft Outlook.
- Overtime as determined by HMSA's business needs.
Duties and Responsibilities
- Utilize and successfully complete on the job training in order to 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.
- Successfully complete on the job training to 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.
- Utilize and successfully complete on the job training to:
- 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.
- 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.
- Document and verbally present problems, recommend solutions, and/or corrective action for issues resulting in customer inquiries.
- Identify and perform routine analysis of the root causes for customer inquiries to be utilized in meeting corporate goals and/or service level agreements.
4. Other duties as assigned.