Remote Medical Claims Adjuster – Payment & Research

Kaiser Permanente; Downey (CA); Hybrid; USD 50,000 - 72,000; Full time

Job summary

KAISER in Downey, California is seeking a Claims Adjuster to review claims, determine payments within authorization limits, and perform research on medical appropriateness using CPT/ICD-9 codes. Responsibilities include ensuring timely processing, staying compliant with CMS, DMHC, DHS and NCQA requirements, and communicating findings to the Lead or Supervisor.

This role supports COB considerations and claims adjudication accuracy.

Qualifications

• 3–5 years of medical claims processing experience in an HMO/Indemnity environment.
• Experience with OCPS claims system; Windows NT; Word; Excel; Lotus Notes.
• Proficient in CPT, ICD-9, and medical terminology; COB/TPL/WC knowledge.
• Ability to analyze medical terminology and ICD-9 coding at job level.
• Strong communication skills in medical claims processing.

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 and education.
• Ensures compliance with CMS, DMHC, DHS and NCQA requirements.
• Proactively works to ensure claims are reviewed and processed timely.

Skills

Medical claims processing

Communication skills

CPT/ICD-9 coding

Medical Terminology

COB/TPL/WC understanding

Education

High School Diploma/GED

Tools

OCPS

Windows NT

Word

Excel

Lotus Notes

Job description

KAISER in Downey, California is seeking a Claims Adjuster to review claims, determine payments within authorization limits, and perform research on medical appropriateness using CPT/ICD-9 codes. Responsibilities include ensuring timely processing, staying compliant with CMS, DMHC, DHS and NCQA requirements, and communicating findings to the Lead or Supervisor.

This role supports COB considerations and claims adjudication accuracy.