JOB SUMMARY:

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.

BASIC QUALIFICATIONS:

Experience

• Three (3) to five (5) years Medical claims processing experience in a HMO/Indemnity environment including technical research and analysis experience.
• 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.

Education

• High School Diploma/GED

License, Certification, Registration

• N/A

Additional Requirements:

PREFERRED QUALIFICATIONS:

• Medical Terminology Certificate Preferred
  PrimaryLocation : California,Downey,Downey Boeing - Independence Park
  HoursPerWeek : 40
  Shift : Day
  Workdays : Mon, Tue, Wed, Thu, Fri
  WorkingHoursStart : 08:00 AM
  WorkingHoursEnd : 04:30 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
  Department : Independence Park - NCA Ongoing Operating Exp - 0315
  Travel : No
  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.

For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:

• Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente’s Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation, and licensure requirements (where applicable), and Kaiser Permanente’s policies and procedures.
• Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.
• Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion.

ESSENTIAL RESPONSIBILITIES:

• 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.

For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:

• Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente’s Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation, and licensure requirements (where applicable), and Kaiser Permanente’s policies and procedures.
• Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.
• Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion