Job details

Claims Adjuster - job 1 of 3

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 Functions:

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.
Education

High School Diploma/GED.

Licenses, Certifications, Registrations

N/A.

Additional Requirements:

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.

Preferred Qualifications:

N/A.

PrimaryLocation : California,Downey,Downey Boeing - Independence Park
HoursPerWeek : 40
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri
WorkingHoursStart : 06:00 AM
WorkingHoursEnd : 02:30 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 - NCA Ongoing Operating Exp - 0315
Travel : No
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.

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3.9

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CEO of Kaiser Permanente

Gregory Adams

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By Kaiser Permanente

Kaiser Permanente exists to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve.

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FUNDING

Public

INDUSTRY

Health Care Services & Hospitals

TEAM SIZE

10000+

LOCATION

Hybrid, based in Oakland, CA

DATE POSTED