Claims Examiner I

KHS•Bakersfield, CA

11h•$21 - $26•Onsite

About The Position

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

Requirements

High School Diploma from an accredited school or equivalent.
Minimum of one (1) year medical Claims Examiner processing experience.
Individual must have good organizational skills and the ability to make good decisions.

Responsibilities

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 guideline.
Perform other job-related duties as required.
Regular Predictable attendance.
Adheres to all company policies and procedures relative to employment and job responsibilities.