Description

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

Primary Location: California,Oakland,Ordway
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 08:00 AM
Working Hours End: 04:30 PM
Job Schedule: Full-time
Job Type: Standard Worker Location: Remote
Employee Status: Regular
Employee Group/Union Affiliation: A04|OPEIU|Local 29
Job Level: Entry Level
Department: Oakland Reg - 1800 Harrison - NCA Ongoing Operating Exp - 0208
Pay Range: $37.47 - $39.41 / hour Travel: No Remote: Work location is the remote workplace (from home) within KP authorized states. Worker location must align with Kaiser Permanente's Authorized States policy. Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.
Requisition #: 1381594

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