Claims Examiner - DEPARTMENT ONLY
Kaiser Permanente
As the nation’s leading not-for-profit health plan, we proudly serve 12.5 million members from more than 600 locations in California, Oregon, Washington, Colorado, Georgia, Maryland, Virginia, Hawaii and Washington D.C. Together, our 217,000+ employees make up an integrated health care delivery system with a mission to improve the lives of our members, employees, and communities.
Join us at the heart of health care and experience an environment where you can play a role in shaping the delivery of care with colleagues just as passionate as you. You’ll be part of a community that’s focused on reaching outside the walls of our facilities to help build every community.
When you join Kaiser Permanente, you stand for total health.
SEIU Local 105: $24.70 – $28.11
May be entitled to translation/bilingual, shift or other wage premiums as governed by the applicable collective bargaining agreement. Please refer to the respective collective bargaining agreement for additional information on such wage premiums: https://www.lmpartnership.org/local-contracts.
Through comprehensive assessment and analysis, adjudicates managed healthcare claims/bills, authorizations 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 analyze claim holds/pends, research and track required claim information to adjudicate professional and hospital claims/bills.
- Proactive and or responsive outreach to provider, members and other customers that could include phone calls, emails or other methods as needed.
- Proactively communicate with internal departments as appropriate to resolve claims issues promptly.
- Provides input to supervisor and training and development team regarding training and educational tools to enhance department production and processes.
- Proactively communicate with internal departments as appropriate to resolve claims issues promptly.
- Provides assistance to prepare materials as needed to the leads, supervisors and managers for external audits.
- Communicate problems and/or trends to leads and management. Understand and apply county, state and federal regulations.
- Other duties as assigned within department job functions.
Basic Qualifications:
Experience
- Minimum three (3) years of claims adjudication experience required.
- High School Diploma or General Education Development (GED) required.
- N/A
- Customer service experience.
- Basic PC skills required.
- Working knowledge of Microsoft Word.
- Ability to work in a in a Labor Management Partnership environment.
- Ability to understand and meet customer needs in a claims setting.
- Ability to apply procedures, practices and methods used in claims processing.
- Skills in analysis, interpretation and application of procedures, practices and methods used in claims adjudication without direct supervision or oversight.
- N/A
PrimaryLocation : Colorado,Englewood,Meridian – Englewood MSSA
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 : C01|SEIU|Local 105
Job Level : Individual Contributor
Job Category : Insurance & Claims
Department : Englewood MSSA Claims – National Claims Service Org – 1608
Travel : No
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.
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