Claims Administrator

POSITION SUMMARY

Under the Manager of Quality Assurance performs duties related to the Dental Department, testing of new system enhancements and changes, maintaining the claims adjudication rules system, preparing departmental calibrations, documenting systems and training staff. Evaluates effectiveness of work processes and propose recommendations for solutions and enhancements. Analyzes and researches business problems and departmental information needs.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Key Responsibilities

• Provides control and oversight of testing system enhancements, employer group benefits claim testing, modifications, and patches.

• Monitors and analyzes the adjudication system's performance regarding the proper application of rules, guidelines, and policies.

• Analyze effectiveness of work processes and propose recommendations for enhancements.

• Works as a lead for the HDS Medicaid system or HDS Commercial System and is responsible for testing, training and ongoing operational support.

• Assists with the research and response to Compliance Claims Monitoring and Audits. Meetings with the auditor(s) in person as required.

• Analyzes and prepares departmental testing and calibration exercises.

• Raises awareness of training issues and serves as an expert on the claims adjudication process.

• Gathers feedback from staff and prepares documentation for the HDS Procedure Code Guidelines annual review.

• Works as a liaison between the Dental Department and the dental consultants.

Other Duties and Responsibilities

• Performs other duties as required or assigned by the Manager of Quality Assurance.

• Investigates and communicates training issues to the department managers and provides training support.

• Monitors and coordinates work with other departments especially ISD, Professional Relations and Membership Services.

• Assists Claims Manager and Customer Service Manager in day-to-day operational issues.

• Serves as back up to Claims Manager and Customer Service Manager

• Assists the Claims Supervisor and Customer Service Manager as necessary during high volume periods or during periods of low staffing.

• Assists with the design, writing, maintenance, and production of departmental manuals, including but not limited to standards of operation, training and user processing manuals.

• Assists the Director, and Dental Operations with special projects.

• Other miscellaneous duties and responsibilities as assigned.

MINIMUM QUALIFICATIONS AND EXPERIENCE

Education

Bachelor's degree in business administration or an equivalent combination of education, training or working experience.

Experience

• Minimum of three (3)- years claims adjudication experience that includes the testing of system rules prior to implementation, preferred, but not required.

• Minimum of one (1) year of experience with staff training that includes developing training material, curriculum and delivery, preferred, but not required.

• Minimum of one (1) year of claims monitoring experience that includes root cause analysis and mitigation, preferred, not required.

• Minimum of one (1) year of claims audit experience that includes preparing and presenting audit documentation, preferred, but not required.

• Minimum of three (3) years of progressively responsible office administration experience, preferably in the areas of servicing groups, group contracts and benefits administration.

Skills and Knowledge

• Ability to organize, analyze and problem-solve somewhat complex problems.

• Ability to handle multiple tasks and prioritize with some distractions and attention to details.

• Ability to communicate both orally and in writing with all levels of staff, customers, consultants/brokers, and vendors on sensitive matters.

• Technical knowledge to understand computer applications for problem-solving and answering staff questions (prefer Windows, Word, Excel, and PowerPoint).

Note: The above information in this description has been designed to indicate the general nature and level of work performed by an employee in this classification. It is not to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications of employees assigned to this job. Hawaii Dental Service has the right to add to, revise, or delete information in this description. Reasonable accommodation will be made to enable qualified individuals with disabilities to perform the essential functions of this position.