Hawaii Medical Service Association Claims Benefit Examiner III in Kapolei, Hawaii
Company:Hawaii Medical Service Assn.Job Title:Claims Benefit Examiner IIIExempt or Non-Exempt:Non-ExemptIsland:OahuCity:KapoleiLocation:KapoleiEmployment Type:Full TimeJob Summary:The purpose of Claims Administration is to provide HMSA members and providers exemplary service through the accurate and timely processing of medical claims. A Claims Benefit Examiner is required to review and make benefit determinations on medical claims in accordance with HMSA’s claim processing guidelines. This involves identifying coding discrepancies, verifying eligibility, determining coverage in accordance with the Plan design, and applying cost containment measures to assist in the claim adjudication process.Duties and Responsibilities:
Process claim suspensions from the system to correct processing discrepancies by reviewing online information while applying HMSA policies and procedures.
Prioritize workload to meet customer expectations and department quality, production, and guidelines.
Concurrently access and utilize multiple databases, software programs, and/or online tools to perform required functions.
Meet or exceed performance objectives and competencies.
Improve claims payment accuracy by identifying pricing inconsistencies and reporting to the QA Trainer.
Assist Benefit Examiner Trainees, Benefit Examiner I’s, and/or Benefit Examiner II’s with processing questions in the absence of the QA Trainer
Participate in test case validation on behalf of the Unit for large system upgrades and/or enhancements.
Attend training as directed by Supervisor.
Other duties as assigned.
Two-year degree from college or university and 1 year’s experience as a Benefits Examiner II or equivalent combination of education and relevant work experience. (i.e., at least 3 years combined experience as a Benefits Examiner I and Benefit Examiner II.)
Must be able to read, analyze and interpret business documents such as HMSA’s Medical Policy Manual, plan certificates, statistical data, marketing memos and documents published by Blue Cross and Blue Shield Association related to program compliance; Federal and/or state government’s documentation pertinent to HMSA’s business (i.e., Federal Register, Medicare guidelines, Hawaii Revised Statutes (H.R.S.).
Must be able to read, analyze and interpret various types of medical documentation submitted with claims, such as invoices, operative reports, radiology reports, itemized bills, and ambulance trip reports.
Must have good communication skills.
Must have the ability to interact with all members of the team, as well as across functional boundaries
Must be able to calculate figures and amounts such as discounts, interest, proportions, andpercentages.
Must be able to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Must be able to interpret a variety of instructions furnished in written, oral, diagram and/or schedule form.
Must be able to learn and gain knowledge of health insurance plans and benefits and coding used in HMSA’s business, such as CPT-4, ICD9-CM, HCPCS, or medical terminology.
Must be able to learn and gain knowledge of facility reimbursement methods, such as DRG, PRG, AWP, case rate, and per diem.
Must have basic knowledge of Microsoft Word and Excel programs.
Work hours are generally during HMSA’s business hours with overtime as determined by HMSA’s business needs on some weekends.