Claims Administrator

POSITION SUMMARY

Under the Manager of Quality Assurance performs duties related to Dental Operations, 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 anda propose recommendations for solutions and enhancements. Analyzes and researches business problems and departmental information needs.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Key Responsibilities

1. Provides control and oversight of testing system enhancements, employer group benefits claim testing, modifications, and patches. Develop comprehensive test strategies, create test cases, and define testing procedures to cover various functionalities and scenarios. Perform manual and automated testing on software applications, websites, or other products to identify bugs, defects, and inconsistencies. Documents identified issues thoroughly, including detailed descriptions, steps to reproduce, screenshots, and severity levels, and submit bug reports to the development team. Maintain detailed test documentation, including test plans, test cases and test reports. Work closely with developers, project managers, and other stakeholders to communicate testing progress, identify potential risks, and resolve issues.
2. Monitors and analyzes the adjudication system's performance regarding the proper application of rules, guidelines, and policies.
3. Analyze effectiveness of work processes and propose recommendations for enhancements. Collaborate with end users to test product functionality and ensure it meets their expectations. Review test results, analyze trends, and identify areas for improvement in the development process.
4. Works as a lead for the HDS Medicaid system or HDS Commercial System and is responsible for testing, training, and ongoing operational support.
5. Assists with the research and response to Compliance Claims Monitoring and Audits. Meetings with the auditor(s) in person as required.
6. Analyzes and prepares departmental testing and calibration exercises.
7. Raises awareness of training issues and serves as an expert on the claims adjudication process.

Other Duties and Responsibilities:

1. Write clear and concise test cases and bug reports.
2. Investigates and communicates training issues to the department managers and provide training support.
3. Monitors and coordinates work with other departments especially ITS, Professional Relations and Group Service Center.
4. Assists Claims Manager and Customer Service Manager in day to day operational issues.
5. Serves as back up to Claims Manager and Customer Service Manager
6. Assists the Claims Supervisor and Customer Service Manager as necessary during high volume period or during periods of low staffing.
7. Assists the Claims Supervisor and Customer Service Manager as necessary during high volume period or during periods of low staffing.
8. Assists with the design, writing, maintenance and production of departmental manuals, including but not limited to standards of operation, training and user processing manuals.
9. Assists the Director, Dental Operations with special projects.
10. Prioritizes and organizes own work to meet both formal and informal deadlines with minimal supervision.
11. 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

1. Three (3) - five (5) years claims adjudication experience that includes the testing of system rules prior to implementation, preferred.
2. One (1) - two (2) years of experience with staff training that includes developing training material, curriculum, and delivery, preferred.
3. One (1) - two (2) years claims monitoring experience that includes root cause analysis and mitigation, preferred.
4. One (1) - two (2) years claims audit or audit experience that includes preparing and presenting audit documentation, preferred.
5. Three (3) - five (5) years of progressively responsible office administration experience, preferably in the areas of servicing groups, group contracts and benefits administration.

Skills and Knowledge

1. Ability to collaborate, organize, analyze and problem-solve complex problems.
2. Ability to manage multiple tasks and prioritize with some distractions and attention to details.
3. Ability to communicate both orally and in writing with all levels of staff, customers, consultants/brokers, and vendors on sensitive matters.
4. Technical knowledge to understand computer applications for problem-solving and answering staff questions (prefer Windows, Word, Excel, and PowerPoint).
5. Exercise the following: strong analytical and problem-solving skills, attention to detail and proficiency in testing methodologies.

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.