Claims Adjuster

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.

COMPANY: KAISER

TITLE: Claims Adjuster

LOCATION: Downey, California

REQNUMBER: 1244257

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.