Claims Adjuster

Kaiser Permanente; Downey (CA); Hybrid; USD 50,000 - 72,000; Full time

Job summary

KAISER in Downey, California is seeking a Claims Adjuster to review claims, determine payments within authorization limits, and perform research on medical appropriateness using CPT/ICD-9 codes. Responsibilities include ensuring timely processing, staying compliant with CMS, DMHC, DHS and NCQA requirements, and communicating findings to the Lead or Supervisor.

This role supports COB considerations and claims adjudication accuracy.

Qualifications

• 3–5 years of medical claims processing experience in an HMO/Indemnity environment.
• Experience with OCPS claims system; Windows NT; Word; Excel; Lotus Notes.
• Proficient in CPT, ICD-9, and medical terminology; COB/TPL/WC knowledge.
• Ability to analyze medical terminology and ICD-9 coding at job level.
• Strong communication skills in medical claims processing.

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 and education.
• Ensures compliance with CMS, DMHC, DHS and NCQA requirements.
• Proactively works to ensure claims are reviewed and processed timely.

Skills

Medical claims processing

Communication skills

CPT/ICD-9 coding

Medical Terminology

COB/TPL/WC understanding

Education

High School Diploma/GED

Tools

OCPS

Windows NT

Word

Excel

Lotus Notes

Job description

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.

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.

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

• Medical claims adjudication experience required-- billing is not a substitute for paying claims.

Notes:

• Remote available; must reside in SoCal
• If ten (10) hour option chosen, shift will be 6:00 am-4:30 pm, back up 8 hour shift will be 8am-430pm

COMPANY: KAISER

TITLE: Claims Adjuster

LOCATION: Downey, California

REQNUMBER: 1435111

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.