Claims Adjuster (P)

KAISER; Downey (CA); On-site; USD 50,000 - 65,000; Full time

Job summary

NALHE is seeking a claims processor in Downey, CA to review and determine payments for medical claims, using ICD-9 and CPT codes as needed. The role requires staying compliant with CMS, DMHC, DHS, and NCQA rules and procedures.

You will assess medical necessity, coordinate benefits, and identify trends to improve accuracy and efficiency in the claims cycle. Strong attention to detail and regulatory knowledge are essential.

Qualifications

• Reviews claims and makes payment determinations.
• Ensures compliance with CMS, DMHC, DHS and NCQA requirements.
• Utilizes ICD-9 and CPT coding as required.

Responsibilities

• Reviews claims and determines payment with authorization limit up to $9,999 per claim.
• Investigates medical appropriateness and coordination of benefits issues.

Skills

Claims processing

Payment determination

ICD-9/CPT coding

Regulatory compliance

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.