9 days old

Claims Adjudication Processor - Ncal

Kaiser Permanente
Oakland, CA 94612

Reviews medical claims to make payment determination to ensure all components, ie., member, provider, authorization, claim and system are valid and correct for accurate processing of claims.

Essential Duties and Responsibilities:

Reviews medical to make payment determination to ensure all components, ie., member, provider, authorization, claim and system are valid and correct for accurate processing.  Conducts research regarding claim completion and appropriateness; and takes necessary actions to resolve claim. Manages work to meet regulatory guidelines.

Essential Responsibilities:

Handles high dollar cases and makes recommendations to ensure appropriate and timely claims payment.

Refers to eligibility, authorization, benefit, and pricing information to determine appropriate course of action (i.e. claim reject / denial, request for additional information, etc.).

Conducts research regarding coordination of benefits issues, fraud and abuse, and third party liability.

Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but not limited to CMS, DMHC, DOC, DHS and requirements of accrediting agencies such as NCQA.Review member/provider claims by checking provider service contracts and other supporting claims documentation in accordance with service agreements.

Coordinates payment agreements with providers, working with appropriate MSA and Regional Contracts Department staff.

Proactively works with other departments, as appropriate, to resolve pending claim issues 

Proactively works to ensure claim review is resolved appropriately based on regulatory guidelines.

Supervisory Responsibilities:   This Job has no supervisory responsibilities.                                         

Corporate Compliance Accountability:

Consistently supports the precepts of Corporate compliance and Principles of Responsibility by maintaining confidentiality, protecting the assets of the organization, acting with integrity, reporting observed fraud and abuse and complying with applicable state, federal and local laws and program policies and procedures.

Competencies:  To perform the job successfully, an individual should demonstrate the following competencies:

Analytical - Able to draw conclusions and formulate recommendations based upon past experience.

Problem Solving - Identifies problems in a timely manner and brings problems to the appropriate person.

Customer Service - In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.

Interpersonal Skills - Maintains confidentiality; treats co-workers, patients and facility visitors with respect.

Oral Communication - Listens and gets clarification to ensure that instructions and requests are fully understood.  

Written Communication - Writes clearly and informatively; reads and interprets written information.

Teamwork - Contributes to building a positive team spirit; balances team and individual responsibilities.               

Physical Demands: Sitting and using computer most of day.

While performing the duties of this Job, the incumbent is regularly required to sit; stand; walk; use hands to finger, handles; reach with hands and arms and talk and hear. The incumbent is occasionally required to sit; climb or balance and stoop, kneel, crouch.

Work Environment:  Office building, cubical configuration. The noise level in the work environment is usually moderate. Little or no physical contact with patients. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


Posted: 2020-03-23 Expires: 2020-05-01

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Claims Adjudication Processor - Ncal

Kaiser Permanente
Oakland, CA 94612

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