Claims Adjudicator II
Primary Location Walnut Creek, California
Worker Location Remote
Job Number 1314137 Date posted 10/21/2024
Navigating the Hiring Process
We're here to support you!
Having trouble with your account or have questions on the hiring process?
Please visit the FAQ page on our website for assistance.
Need help with your computer and browser settings?
Please visit the Technical Information page for assistance or reach out to the web manager at kp-hires@kp.org.
Do you need a reasonable accommodation due to a disability?
A reasonable accommodation is any modification or adjustment that enables you to fully participate in completing the following:
- Online Submissions
- Pre-Hire Assessments
- Interview Process
Please submit your accommodation request and an HR Representative will contact you.
Description:
Essential Responsibilities:
Job Summary:
Adjusts and Adjudicates multiple lines of business for first pass in a timely manner to ensure compliance to departmental and regulatory turn-around time and quality standards. Reviews claims and makes payment/adjustment determination to ensure all components, ie., member, provider, authorization, claim and system are valid and correct for accurate processing. Conducts research regarding claim completion and appropriateness; identifies errors and takes necessary actions to resolve claim. Manages work to meet regulatory guidelines.
Essential Responsibilities:
- Reviews claims and makes payment determination with authorization limit to a specific dollar limit (ie. $19,999/claim.).
- Checks with Lead and Supervisor for any claim exceeding specific dollar threshold (ie. $19,999).
- Reviews and evaluates claims for proper and correct information including, correct member, provider, authorization, and billing information on which to base payment determination.
- Refers to eligibility, authorization, benefit, and pricing information to determine appropriate course of action (i.e. claim reject / denial, request for additional information, etc.).
- Conducts research regarding coordination of benefits issues, fraud and abuse, and third party liability.
- Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but not limited to CMS, DMHC, DOC, DHS and requirements of accrediting agencies such as NCQA.
- Prepares material for audits and provides assistance to Lead and Supervisor during audit.
- Assists with the preparation of materials for audits (including Quality, Compliance, and Regulatory audits) and provides assistance to Lead and Supervisor during audit.
- Review member/provider claims by checking provider service contracts and other supporting claims documentation in accordance with service agreements.
- Coordinates payment agreements with providers, working with appropriate MSA and Regional Contracts Department staff.
- Proactively works to ensure claim review is resolved appropriately.
Grade: 6
Basic Qualifications:
Experience
- Three (3) years medical claims adjudication experience.
- Experience in processing multiple types of medical claims and lines of business required (inpatient / outpatient, third party billing, hospital, and professional.)
Education
- High School Diploma or GED required.
License, Certification, Registration
- N/A
Additional Requirements:
- Knowledge of claim processing regulatory guidelines / mandates, ie HIPAA, Timeliness Standards, Medical Terminology, COB / TPL/ WC insurance guidelines.
- Knowledge of various payment methodologies & government reimbursement guidelines.
- Knowledge of claims categorization / codification guidelines (Revenue Codes, Occurrence & Condition codes, CPT/HCPCs codes, ICD9 and ICD10 Diagnosis & Procedure Codes).
- Must pass basic PC Skills test.
- Must pass medical terminology test.
- Related Experience Field: Medical Claims Experience.
- Working knowledge of CPT, ICD-9, ICD-10, Medical Terminology, COB/TPL/WC. Excellent verbal, written and analytical skills.
- Demonstrate ability to utilize Medical Terminology and International Classification Diagnosis (ICD-9, ICD 10) coding at a level appropriate to the job.
- Must be able to work in a Labor Management Partnerships environment.
Preferred Qualifications:
- Four (4) years medical claims adjudication experience preferred in processing multiple types of medical claims and lines of business (inpatient / outpatient, third party billing, hospital, and professional).
- Experience with SNF, DME, or Home Care/Hospice Claims processing preferred.
- Excellent skills in communication preferred.
- Medical Terminology Certificate preferred.
Primary Location: California,Walnut Creek,2880 Shadelands
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 08:00 AM
Working Hours End: 04:30 PM
Job Schedule: Full-time
Job Type: Standard
Worker Location: Remote
Employee Status: Regular
Employee Group/Union Affiliation: A01|SEIU|United Healthcare Workers West
Job Level: Individual Contributor
Department: Walnut Crk 2880 Prk Shadelands - HP Func-DME Preauthorize Unit - 0208
Pay Range: $35.48 - $37.33 / 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. Submit Interest
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. Submit Interest
