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.
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
License, Certification, Registration
Additional Requirements:Preferred Qualifications:- Medical Terminology Certificate Preferred
- Medical claims adjudication experience required-- billing is not a substitute for paying claims.
Notes:- Remote available; must reside in SoCal
- If ten (10) hour option chosen, shift will be 6:00 am-4:30 pm, back up 8 hour shift will be 8am-430pm
Primary Location: California,Downey,Downey Boeing - Independence Park
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 06:00 AM
Working Hours End: 04:30 PM
Job Schedule: Full-time
Job Type: Standard
Employee Status: Regular
Worker Location: Remote
Employee Group/Union Affiliation: B01|SEIU|Local 399
Job Level: Individual Contributor
Department: Independence Park - NCA Ongoing Operating Exp - 0315
Pay Range: $40.83 - $45.24 / hour Kaiser Permanente strives to offer a market competitive total rewards package and is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not reflect the full value of our total rewards package. Actual base pay determined at offer will be based on labor market data, internal alignment, and a candidate's years of relevant work experience, education, certifications, skills, and geographic location.
Travel: No
