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Claims Adjuster

Primary Location Downey, California Worker Location Remote Job Number 1322217 Date posted 12/19/2024
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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 $9,999.

  • 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.


Pay Grade: 13


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, ICD-9, Medical Terminology, COB/TPL/WC

  • Demonstrate ability to utilize Medical Terminology and International Classification

  • Diagnosis (ICD-9), HCPCS&CPT coding at a level appropriate to the job.



    Education



    • High School Diploma/GED


    License, Certification, Registration



    • N/A


    Preferred Qualifications:



    • Medical Terminology Certificate preferred.

    Primary Location: California,Downey,Downey Boeing - Independence Park Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 08:00 AM Working Hours End: 04:00 PM Job Schedule: Full-time Job Type: Standard Worker Location: Remote Employee Status: Regular Employee Group/Union Affiliation: B01|SEIU|Local 399 Job Level: Individual Contributor Department: Independence Park - NCA Ongoing Operating Exp - 0315 Pay Range: $37.04 - $41.03 / hour The ranges posted above reflect the location in the job posting. The salary range may vary if you reside in a different location or state than the location posted. Travel: No Remote: Work location is the remote workplace (from home) within KP authorized states. Worker location must align with Kaiser Permanente's Authorized States policy. At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.

    Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:

  • Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation, and licensure requirements (where applicable), and Kaiser Permanente's policies and procedures.

  • Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.

  • Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion.
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