Adjustment Examiner I

As an Adjustment Examiner I at Capital Blue Cross, your primary responsibility is to process claim adjustments in the FACETS system within established timeframes. You'll research and resolve error and warning messages, ensuring accurate adjudication and effective communication with providers to gather necessary information. This role also involves collaboration with various departments and vendors to facilitate the claims process, making attention to detail and strong communication skills essential.

To qualify for the Adjustment Examiner I position at Capital Blue Cross, you must have a high school diploma or GED. Relevant experience in FACETS claim coding and processing is strongly preferred, along with a basic understanding of HIPAA regulations. Skills in written and verbal communication are crucial, as you'll be expected to interact with various stakeholders and process documentation accurately.

While previous experience specifically in claims processing is preferred for the Adjustment Examiner I role at Capital Blue Cross, candidates who possess knowledge of claims processing systems like FACETS, along with strong technical skills in databases and office software, are encouraged to apply. The role is designed for someone eager to learn and grow within the organization.

At Capital Blue Cross, we offer a robust benefits package for our Adjustment Examiner I employees, which includes medical, dental, and vision coverage, a retirement plan, and generous paid time off. Employees can also take advantage of tuition reimbursement and volunteer opportunities to give back to the community. We believe that investing in our employees’ well-being helps us create a positive work environment.

Success as an Adjustment Examiner I at Capital Blue Cross relies on sharp analytical skills, attention to detail, and proficiency in using claims processing tools. Familiarity with FACETS and knowledge of HIPAA regulations are important. Additionally, strong communication skills, both verbal and written, will help you effectively gather and relay necessary information to your team and external providers.

In a busy claims processing environment, I prioritize tasks based on deadlines and urgency. I create a list of items to address and systematically tackle them one by one while ensuring that any immediate concerns are addressed promptly. Using organizational tools and open communication with my team helps me stay on track and support efficient operations.

I have hands-on experience with the FACETS claims processing system, where I have managed claim adjustments and resolved discrepancies using its various tools. My familiarity with FACETS has allowed me to quickly identify errors and communicate effectively with other departments to ensure timely adjudication of claims.

To resolve an error message in the claims processing system, I would first carefully review the message details to understand the root cause. Then, I would research relevant documents and claim history, utilize available tools within the FACETS system, and reach out to team members or providers for additional information if necessary to correct the issue collaboratively.

To ensure compliance with HIPAA regulations, I make it a priority to handle all patient information sensitively and securely. I have a thorough understanding of HIPAA principles and adhere strictly to protocols during claims processing. Continuous training and staying updated on compliance rules are essential practices I follow to maintain HIPAA standards.

In my previous role, I encountered a claim that required further documentation from a provider. I promptly reached out via phone, clearly explaining the need and the urgency. After establishing a rapport and providing a timeline for the additional information, the provider promptly sent over the necessary paperwork, allowing me to resolve the claim issue quickly.

My approach to challenging claim discrepancies involves a systematic review of the case details. I analyze each element of the claim and assess potential causes before reaching out to relevant departments or providers. I firmly believe that open communication and thorough documentation can lead to effective resolutions and improved processes.

I am very comfortable using various computer applications and software tools essential for claims processing. My background includes proficiency in Microsoft Office, database management, and other end-user computing tools. I enjoy leveraging technology to streamline processes and enhance productivity in the workplace.

I am drawn to Capital Blue Cross because of its commitment to fostering a supportive work environment and community involvement. The Adjustment Examiner I role aligns perfectly with my skills and interests, and I am excited to contribute to an organization recognized as one of the best places to work. Being part of a team dedicated to improving the health and well-being of our community is also deeply meaningful to me.

I utilize digital task management tools to organize my work and set reminders for important deadlines. My focus is maintained by breaking larger tasks into smaller, manageable steps and taking short breaks to recharge. I also prioritize clear communication with my team to ensure we are aligned on our goals and expectations.

I view constructive criticism as an opportunity for growth and improvement. When receiving feedback, I actively listen and seek to understand the perspective of the reviewer. I ask questions if necessary and reflect on how I can apply the feedback to enhance my performance. I believe this mindset fosters a culture of learning and collaboration.