Claims Examiner I

Kern Family Health Care; Bakersfield (CA); On-site; USD 28,929 - 44,083; Full time

Job summary

Kern Health Systems is seeking a dedicated Claims Examiner in California to review and process medical and facility claims from contracting and non-contracting providers and subscribers for payment in a timely and accurate manner. This role ensures correct application of contract benefits, policies, and procedures and supports efficient claims auditing.

You will apply policy guidelines, verify eligibility, identify billing errors and potential fraud, and route complex cases to appropriate

Qualifications

• High School Diploma required.
• Minimum of one year medical Claims Examiner processing experience.

Responsibilities

• Review and process all types of medical and facility claims for payment in a timely and accurate manner.
• Apply correct contract benefits, policies and procedures.
• Deny inappropriate claims following policy guidelines.
• Prepare claims that must be routed to other departments for further review.
• Review difficult claims with guidance from Claims Supervisor.
• Identify billing errors and possible fraudulent claims submissions.
• Obtain eligibility verification and other health insurance coverage by Internet or POS.
• Responsible for correct manual calculation of benefits when applicable.
• Identify possible CCS eligible claims for further investigation.
• Report overpayment refund requests on SharePoint log.
• Maintain productivity and quality in accordance with established guideline.
• Perform other job-related duties as required.
• Regular predictable attendance.
• Adheres to all company policies and procedures relative to employment and job responsibilities.

Education

High School Diploma

Job description

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).

Work Location

On‑Site

About Us

Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.

About The Role

Under management direction, responsible for reviewing and processing all types of medical and facility claims from contracting and non‑contracting providers and from subscribers and enrollees for payment in an accurate and timely manner. Responsible for applying correct contract benefits, policies and procedures.

This position is responsible for claims auditing and payment functions for a Knox‑Keene licensed health maintenance organization (HMO).

Essential Duties And Responsibilities

Resolve system suspended claims for:

• PCPs
• Labs
• Radiology
• Less complicated specialists
• Physical Therapy

• Deny inappropriate claims following policy guidelines.
• Prepare claims that must be routed to other departments for further review.
• Review difficult claims with guidance from Claims Supervisor.
• Responsible for identifying billing errors and possible fraudulent claims submissions.
• Obtain eligibility verification and other health insurance coverage by Internet or POS.
• Responsible for correct manual calculation of benefits when applicable.
• Responsible for identifying possible CCS eligible claims for further investigation.
• Report overpayment refund requests on SharePoint log.
• Maintain productivity and quality in accordance with established guideline.
• Perform other job‑related duties as required.
• Regular predictable attendance.
• Adheres to all company policies and procedures relative to employment and job responsibilities.

Employment Standards

High School Diploma from an accredited school or equivalent.

Minimum of one (1) year medical Claims Examiner processing experience.

Individual must have good organizational skills and the ability to make good decisions.

Compensation

Pay range shown reflects the full range for this position. Initial offers are typically positioned between the minimum and midpoint, based on qualifications and internal equity.

Pay Range: Minimum: $21.15 Mid‑Point: $26.44 Maximum: $31.73

We are an equal opportunity employer, dedicated to a policy of non‑discrimination in employment on any basis.