Claims Examiner, MUST RESIDE IN COLORADO

Kaiser Permanente; Denver (CO); On-site; USD 60,000 - 80,000; Full time

Job summary

Kaiser Permanente in Denver, CO seeks a Claims Adjudicator to assess and adjudicate managed healthcare claims, authorizations and referrals for payment or denial according to contract and regulatory requirements.

The role requires a minimum of three years' experience in claims adjudication, a high school diploma or GED, strong customer service and basic PC skills, and the ability to work independently within our Labor Management Partnership environment.

Qualifications

• Minimum three (3) years of claims adjudication experience required.
• High School Diploma or GED required.
• Strong customer service experience and basic computer skills.

Responsibilities

• Analyze claims holds/pends and adjudicate professional and hospital claims/bills.
• Outreach to providers, members and customers by phone, email, or other methods as needed.
• Communicate with internal departments to resolve claims issues promptly.
• Assist leads with materials for audits and training tools.
• Identify problems/trends and report to leads and management.

Skills

Customer service

Attention to detail

Analytical thinking

Team communication

Education

High School Diploma/GED

Tools

Microsoft Word

Basic PC skills

Job description

-May be entitled to translation/bilingual, shift or other wage premiums as governed by the applicable collective bargaining agreement. Please refer to the respective collective bargaining agreement for additional information on such wage premiums:https://www.lmpartnership.org/local-contracts.

Job Summary

Through comprehensive assessment and analysis, adjudicates managed healthcare claims/bills, authorizations and referrals, for payment or denial within contract agreement and/or regulatory requirements. Performs these duties using industry standard knowledge of managed healthcare claim/bill payment processing and medical regulations, verifies and updates relevant data into various computerized internal and external systems.

Essential Responsibilities

• For all lines of business analyze claim holds/pends, research and track required claim information to adjudicate professional and hospital claims/bills.
• Proactive and or responsive outreach to provider, members and other customers that could include phone calls, emails or other methods as needed.
• Proactively communicate with internal departments as appropriate to resolve claims issues promptly.
• Provides input to supervisor and training and development team regarding training and educational tools to enhance department production and processes.
• Proactively communicate with internal departments as appropriate to resolve claims issues promptly.
• Provides assistance to prepare materials as needed to the leads, supervisors and managers for external audits.
• Communicate problems and/or trends to leads and management. Understand and apply county, state and federal regulations.
• Other duties as assigned within department job functions.

Basic Qualifications

Experience

• Minimum three (3) years of claims adjudication experience required.

Education

• High School Diploma or General Education Development (GED) required.

License, Certification, Registration

• N/A

Additional Requirements

• Customer service experience.
• Basic PC skills required.
• Working knowledge of Microsoft Word.
• Ability to work in a in a Labor Management Partnership environment.
• Ability to understand and meet customer needs in a claims setting.
• Ability to apply procedures, practices and methods used in claims processing.
• Skills in analysis, interpretation and application of procedures, practices and methods used in claims adjudication without direct supervision or oversight.

Preferred Qualifications

• N/A