Claims Examiner I/II

Kern Health Systems; Bakersfield (CA); On-site; USD 29,000 - 44,000; Full time

Job summary

Kern Health Systems in California is seeking a Medical Claims Examiner on-site to review and process all types of medical and facility claims for payment accurately and timely, applying correct contract benefits and procedures. The role emphasizes claims auditing, denial of inappropriate claims, eligibility verification, and collaboration with supervisors to resolve complex cases.

The position requires high school diploma and at least one year of related experience, with a strong focus on

Qualifications

• High School Diploma or equivalent.
• Minimum of one year medical Claims Examiner processing experience.
• Strong organizational skills and the ability to make good decisions.

Responsibilities

• 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.
• Calculate benefits manually when applicable.
• Identify CCS eligible claims for further investigation.
• Report overpayment refund requests on SharePoint log.
• Maintain productivity and quality per guidelines.
• Attend work regularly and adhere to policies.

Education

High School Diploma (or equivalent)

Job description

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.

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