Claims Examiner I/II - Temporary

Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.

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).

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 guidelines.
• 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.
Up to (1-2) years of medical claim payment or medical billing processing experience
Experience investigating COB.
Ability to calculate usual and prevailing fees.
Health maintenance organization (HMO) claims payment-processing experience is highly desirable.

Computerized on-line data entry systems; organizational structure of medical claims processing; methods and procedures utilized in medical claims processing; medical terminology; CPT & ICD-9 coding; COB & subrogation investigation. 

Adapt to a rapidly evolving work environment; work independently; communicate with a variety of personnel and providers.

Computerized on-line data entry systems; organizational structure of medical claims processing; medical terminology; HCPCS, CPT & ICD-10 coding, UB04 and CMS1500 forms.