Claims Adjuster - Downey, United States - Kaiser Permanente

Kaiser Permanente

Verified Company

Downey, United States

3 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

Job Summary:

Reviews claims and makes payment and benefit determination.

Conducts research as it relates to claims processing for medical appropriateness, and diagnosis, using ICD-9 codes and CPT codes as required.

Essential Responsibilities:

Reviews claims and makes payment determination with authorization limit to $9,999 per claim.
Conducts research regarding medical appropriateness, coordination of benefits issues, fraud and abuse, and third party liability.
Checks with Lead and Supervisor for any claim exceeding $9,99
Provides input to Supervisor regarding trends related to training, education to enhance department production and processes.
Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but limited to CMS, DMHC, DHS and requirements of accrediting agencies such as NCQA.
Proactively works to ensure claims are review & processed timely.

Basic Qualifications:

Experience

Three (3) to five (5) years Medical claims processing experience in a HMO/Indemnity environment including technical research and analysis experience.
Claims System OCPS; Windows NT; Word, Excel, Lotus Notes. Excellent skills in communication Medical Claims Processing.
CPT, ICD9, Medical Terminology, COB/TPL/WC
Demonstrate ability to utilize Medical Terminology and International Classification
Diagnosis (ICD9), HCPCS&CPT coding at a level appropriate to the job.

Education

High School Diploma/GED

License, Certification, Registration

Additional Requirements:

Preferred Qualifications:

Medical Terminology Certificate Preferred

PrimaryLocation :
California,Downey,Downey Boeing - Independence Park

HoursPerWeek : 40

Shift :
Day

Workdays :
Mon, Tue, Wed, Thu, Fri

WorkingHoursStart : 08:00 AM

WorkingHoursEnd : 04:30 PM

Job Schedule :
Full-time

Job Type :
Standard

Employee Status :
Regular

Employee Group/Union Affiliation :
B01|SEIU|Local 399

Job Level :
Individual Contributor

Job Category :
Insurance & Claims

Department :
Independence Park - Claims And Referrals - 0315

Travel :
No