Claims Adjuster - Research & Resolution

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 of 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.

• 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 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.

Experience

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

Education

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

Additional Requirements:

• Basic PC skills.
• Working knowledge of Microsoft Word.
• Ability to work 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.