Claims Examiner

The Company:

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.

The Culture:

AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.

These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.

The Opportunity:

Processing claims payment/denial according to plans policies and procedure, contracts, benefits and in compliance with the state and federal regulations.

Primary Duties and Responsibilities:

• Adjudicate claims based on contract terms and benefits rules
• Conduct advance level claims research whenever necessary to resolve pends due to system edit
• Identify billing errors and communicate to the supervisor or manager
• Ensure that pended claims are forwarded to the appropriate department for resolution
• Monitor daily work assignment to ensure that department turnarounds are being met
• Process resubmitted claim reversal and adjustments
• Process coordination of benefit claims by plan policy and procedure
• When required will support Data Entry Processes
• Meet performance goals for quality and claims turnaround as set by the department Key Performance Indicators, self-monitor performance and strive for continues improvement
• Perform other duties and responsibilities, as assigned.
• Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.

Requirements:

• High school diploma or equivalent required
• Two year of claims processing experience required or combination of relevant education, experience or credentialing
• Excellent attendance, must be punctual and reliable
• Ability to adjudicate complex claims accurately and in a timely manner
• Strong verbal and written communication in English
• Requires operation of general office equipment to include; PC, fax/copy machine and ACD Mitel Phones.
• Intermediate skill using Microsoft Programs; Word, Excel, Outlook and PowerPoint.
• Must have the ability to read, analyze, and interpret business documents such as Claims workflows, Medical Policies, Claims Resolutions, Medicare and Medicaid guidelines.
• Health care insurance and medical coding, billing and payment guidelines required and knowledge of CPT, ICD-9/ICD-10, HCPCS, UB04 forms, and CMS- 1500 forms as they relate to insurance payments

Preferred Requirements

• Certified professional coder (CPC)
• Previous experience with QNXT

Mental, Physical and Environmental Demands:

• Inside working conditions.
• Requires operation computer workstation, including keyboard and video display terminal.
• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Salary range: $17.00 - $24.00 an hour

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.