Claims Examiner I/II

Kern Family Health Care; Bakersfield (CA); On-site; USD 44,000 - 66,000; Full time

Job summary

Kern Health Systems is hiring an on-site Medical Claims Examiner to review and process medical and facility claims with accuracy and timely payment. You will apply contract benefits and policies, audit suspensions, and help prevent erroneous payouts.

Required is a high school diploma and at least one year of claims experience, with strong attention to detail and knowledge of billing guidelines. Compensation reflects California ranges and offers on-site work.

Qualifications

• Minimum of one year medical Claims Examiner processing experience.
• Ability to review and apply contract benefits and policies accurately.
• Attention to detail to identify billing errors and potential fraud.

Responsibilities

• Review and process all types of medical and facility claims for payment.
• Apply correct contract benefits, policies and procedures.
• Audit claims and resolve system suspended claims for PCPs, labs, radiology, and therapy.
• Deny inappropriate claims following policy guidelines and route complex cases for review.
• Obtain eligibility verification and other health coverage information.
• Maintain productivity and quality per established guidelines.

Skills

Medical Claims

Claims Auditing

Education

High School Diploma

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.

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