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Claims Examiner

Company: AlohaCare
Location: Honolulu
Posted on: March 20, 2023

Job Description:

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 Company: 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 paymentsPreferred
Requirements -
Certified professional coder (CPC) -
Previous experience with QNXTMental,
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.

Keywords: AlohaCare, Honolulu , Claims Examiner, Other , Honolulu, Hawaii

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