Claim Services Adjustment Representative

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We focus on your health and pay 100% for your family's medical insurance and provide 20 days of paid personal time off during your first year!

Claim Services Adjustment Representative

Department: Claim Services

FLSA Status: Full Time, Non-Exempt

Salary Level: 3

Position Summary:

Researching, analyzing, and reprocessing of claims requiring adjustments due to incorrect payments, payments to an incorrect payee, claim check edit reviews, refund checks received, or any other adjustments that may need to be done to a claim.

Essential Duties & Responsibilities:

• Review check register for incorrect processing
• Void system checks and reprocess claims accordingly.
• Check research for system checks and/or stop payments.
• Maintain refund documentation of checks, and the completion of the claim adjustment.
• Document and reprocess incorrectly paid claims, corrected claims submitted, and previously denied claims.
• Reprocess Claims reviewed for Claim Check Edit Overturned Denial or Upheld Denial determinations or Claims Reconsideration Report, or any claims reprocessing request spreadsheets.
• Participate in batch claims reprocessing requests.
• Retrieve document records from theELA Viewer or EDI Claim Viewer
• Have pertinent documents scanned or saved for audit purposes.
• Participate in any Claims Processing and Claims Adjustments/Reconsideration Training
• Help with updating any claims policies and procedures.
• Perform other related duties as required or assigned.

Required Education and Experience:

The individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Annual training as required by the training policy located in the UHA Policy Manual
• Introduction to Medical Terminology, Anatomy and Pathophysiology
• Introduction to Medical Billing
• Introduction to Medical Coding
• HIPAA Privacy and Security
• URAC Standards as applicable to Job
• Able to navigate through internal and external computer systems including Microsoft Word and Excel, and have proficient PC keyboarding skills
• Able to use acquired skills & knowledge and willing to learn new skills
• Able to interpret group benefit plan coverages and provider contracts.
• Able to analyze and calculate Coordination of Benefits information
• Able to work as a contributing team member toward achieving management’s stated goals
• High School diploma
• Two years of work experience in an office setting, preferably associated within the healthcare industry
• Able to use ten key and typewriter by touch with a minimum of 10,000 keystrokes per hour

Preferred and Advanced Qualifications:

• CPC (Certified Professional Coder) preferred but not required

• Knowledge of any medical claims processing software applications
• Experience researching why claims have processed a certain way.

Physical Demands/Working Conditions:

The work environment characteristics described here are representative of those associate encounters while performing the essential functions of this job.

This position is a work from home upon manager’s approval

Vehicles

• None required

Must be a current Hawaii resident**

Competitive compensation & excellent benefits offered

Visit our website at https://uhahealth.com/page/career-opportunities to apply and for details about vacant positions