Claims Examiner

Job Summary:

Through comprehensive assessment and analysis, adjudicates managed healthcare claims/bills, authorizatons and referrals, for payment or denial within contract agreement and/or regulatory requirements. Performs these duties using industry standard knowledge of managed healthcare claim/bill payment processing and medical regulations, verifies and updates relevant data into various computerized internal and external systems.

Essential Responsibilities:

• For all lines of business, including MMA, Part D, analyze claim holds/pends, research and track required claim information to adjudicate professional and hospital claims/bills.

• Understand and apply county, state, and federal regulations.

• Proactively communicate with internal departments as appropriate to resolve claims issues promptly.

• Provies input to supervisor and Training and Development team regarding training and educational tools to enhance department production and processes.

• Provides assistance to prepare materials as needed to leads, supervisors, and managers for external audits.

• Communicate problems and/or trends to leads and management.

• Other duties as assigned within the job functions

  Basic Qualifications:

  Experience

• Minimum two (2) years claims adjudication experience or two (2) years of internal claims (encounter) processing experience.

  Education

• High School Diploma or General Education Development (GED) required.

  License, Certification, Registration

• N/A

  Additional Requirements:

• Must be able to work in a Labor Management Partnership environment

• Knowledge of medical terminology and international classification of Disease (ICD-10) and Current Procedure Terminology (CPT)

• Basic PC skills

• Working knowledge of Microsoft Word and email systems

• Ability to do basic math (addition, subtraction, multiplication)

• Ability to understand and meet customer needs in a claims setting

• Attention to detail

• Skills in analysis, interpretation and application of procedures, practices and methods used in claims adjudication without direct supervision or oversight

  Preferred Qualifications:

• Working knowledge of Microsoft Excel preferred

COMPANY: KAISER

TITLE: Claims Examiner

LOCATION: Pleasanton, California

REQNUMBER: 1307982

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.