Research & Resolution Claims Adjuster - Must Reside in Colorado

Kaiser Permanente; Denver (CO); On-site; USD 52,000 - 76,000; Full time

Job summary

Kaiser Permanente is seeking a claims analyst to assess and analyze inquiries related to medical claims, authorizations and adjustments. Under general supervision, you will apply knowledge of claim processing, contracts, and regulations to determine correct processing and potential adjustments.

Responsibilities include researching claims, documenting case summaries, coordinating with other departments, and applying findings to similar claims to improve upstream processing accuracy.

Qualifications

• Basic PC skills and ability to work with standard office software.
• Experience with medical claims processing in a health plan environment preferred.
• Strong knowledge of ICD-10 and CPT terminology.

Responsibilities

• Verify the intent of inquiries and ensure adherence to contracts and regulations.
• Locate information relevant to the claim using available resources.
• Determine how claims were processed and research denied claims.
• Make determinations for adjustments as warranted.
• Document clear case summaries for review.
• Take next steps to resolve inquiries and educate on process improvements.
• Apply findings to similar claims to improve upstream processing accuracy.
• Research Kaiser Permanente payment checks and classify the reason for returns.
• Other duties as assigned.

Skills

Basic PC skills

Customer service

Claims processing knowledge

Medical terminology

ICD-10/CPT knowledge

Problem solving

Microsoft Word

Education

High School Diploma or GED

Tools

Microsoft Word

Microsoft Excel

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:

Under general supervision, assess and analyze inquiries related to medical claims/bills, authorizations and adjustments for payment or denial within contract agreement or regulatory requirements using knowledge or medical claim/bill payment processing and medical regulations. Investigates/researches claims that may require reprocessing due to system errors, contract changes, examiner errors, regulatory requirements or fee schedule changes. Coordinates with other health plan departments to correct data (e.g., benefit or systems errors) as necessary. Considers how actions contribute to quality outcomes and member/provider satisfaction.

Essential Responsibilities:

• Verify the intent of the inquiry: Utilizes knowledge of organizational policies and procedures to ensure adherence to contractual agreements and non-contracted pricing arrangements along with compliance with government regulations.
• Locate the necessary information relevant to the claim(s): Leverages information from the inquiry and using available resources.
• Determine how the related claim(s) was originally processed. Researches services rendered utilizing all available resources to determine if the claim was processed correctly. Researches denied claims utilizing all information available to determine if the claim was denied correctly.
• Make organizational determination: Use the information gained in steps 1, 2 and 3 to review the original claim outcome and determine if an adjustment is warranted.
• Document determination: Development of a clear and concise case summary, which may be subject to review.
• Take appropriate next steps to resolve the inquiry (e.g., adjust claim related pends and holds, policy, benefit or contract update/review, CHATS, CRM, Call Center or other organizational area education or closure of issue with no further action).
• Apply research findings across a broader population of claims with similar issues (benefit, contract, membership, etc.).
• Provide input regarding training and educational opportunities that aid in improving upstream processing accuracy and outcomes, identifying error trends.
• Research returned Kaiser Permanente claims payment checks and classify the reason for their return.
• Other duties may be assigned within department job functions.

Basic Qualifications:

Experience

• Minimum four (4) years of medical claims in an health plan environment adjudication experience (HMO, PPO, Indemnity environment). Which includes one (1) year of processing high complexity claims. IE: Adjustments, Transplants and High Dollar.

Education

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

License, Certification, Registration

• N/A

Additional Requirements:

• Basic PC skills.
• Working knowledge of Microsoft Word.
• Ability to work in a in a Labor Management Partnership environment.
• Customer service skills and the ability to understand Kaiser Permanente customer needs in a claims setting.
• Ability to apply procedures, practices and methods used in claims processing.
• Working Knowledge of medical terminology and international classification of Disease (ICD-10) and Current Procedure Terminology (CPT).
• Ability to apply timely and accurate requirements of all state and federal regulatory guidelines.
• Ability to demonstrate complex problem solving and decision making.

Preferred Qualifications:

• Working knowledge of Microsoft Excel.
• Demonstrated knowledge of medical terminology and international classification of Disease (ICD-10) and Current Procedure Terminology (CPT).
• AA degree, accounting or business related preferred.