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Medical Claims Examiner

1 month ago

Walnut Creek, California, United States Kaiser Permanente Full time
Job Summary

As a Claims Adjudicator II at Kaiser Permanente, you will play a critical role in ensuring the timely and accurate processing of medical claims. Your expertise in claim processing regulatory guidelines, medical terminology, and coding will enable you to make informed payment determinations and resolve claims efficiently.

Key Responsibilities
  • Review claims and make payment determinations with authorization limits to ensure compliance with regulatory guidelines.
  • Conduct research on claim completion and appropriateness, identifying errors and taking necessary actions to resolve claims.
  • Manage work to meet regulatory guidelines, ensuring timely and accurate processing of claims.
  • Collaborate with Lead and Supervisor to resolve claims exceeding specific dollar thresholds.
  • Utilize knowledge of government regulatory policies and procedures to ensure compliance with government regulations.
Requirements
  • Three years of medical claims adjudication experience, with expertise in processing multiple types of medical claims and lines of business.
  • High School Diploma or GED required.
  • Knowledge of claim processing regulatory guidelines, medical terminology, and coding.
  • Ability to work in a Labor Management Partnerships environment.
Preferred Qualifications
  • Four years of medical claims adjudication experience, with expertise in processing multiple types of medical claims and lines of business.
  • Experience with SNF, DME, or Home Care/Hospice Claims processing.
  • Medical Terminology Certificate preferred.