Description: 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 andanalysis 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. 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: 02:30 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: B01SEIULocal 399 Job Level: Individual Contributor Department: Independence Park - NCA Ongoing Operating Exp - 0808 Pay Range: $33.28 - $36.87 / hour The ranges posted above reflect the location in the job posting. The salary range may vary if you reside in a different location or state than the location posted. Travel: No At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing. 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. Submit Interest Load More
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