Claims Processor

Kaiser Permanente-posted 21 days ago
Entry Level
Downey, CA
5,001-10,000 employees
Religious, Grantmaking, Civic, Professional, and Similar Organizations
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Under general supervision provides patient/visitor reception, obtains employer and carrier information for billing, prepares Doctors First Reports of Injury, identifies appropriate ICD-9 codes, prepares and distributes supplemental and medical/legal reports, creates patient accounts and charts. Must be able to demonstrate the ability to work collaboratively with co-workers and supervisor and possess excellent organizational skills. Must be customer service oriented. Extensive contact with members, non-members, physicians, and third party administrators/carriers; requires excellent interpersonal skills.

  • Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities and applicable state, federal and local laws.
  • Reviews patients medical records to locate the history, treatment, prognosis and other medical information relevant to reporting of the patients condition. For Workers Compensation claims, processing may complete Doctors First Report of work injury, check for proper authorization, obtain physicians signature and file report within the five day time limit pursuant to California Labor Code; at periodic intervals during patients continuing treatment, but no less than each 45 days, review patient medical records and prepare narrative style medical progress report describing patients current complaints, treatment, time off, work orders, light duty and other medical information relevant to the patients industrial claim; consults with treating physician as necessary.
  • Creates and registers patient account on automated billing system, inputting patient and employer demographic data to prepare account for billing; enters account notes when account has previously been established at another medical center; consolidates or corrects duplicate accounts by using appropriate on-line system functions; requires knowledge of automated billing system .
  • Interviews patient and gathers information, contacts employers/carriers to obtain authorization for treatment. Schedules follow-up appointments reports status to employers/carriers, and expedites needed referrals as directed.
  • Audits all patients medical and hospital records, including ambulance and pharmacy records, accesses and screens systems to identify industrial services paid for by Kaiser for rebilling to the patients employer or workers compensation insurance carrier; requires knowledge of medical terminology, CPT procedure codes, anatomy and physiology to identify all billable services, including secondary medical conditions directly or indirectly related to the principle industrial condition being claimed or litigated by the patient; consults with treating physician on complex cases; decisions made affect revenue.
  • Selects ICD diagnostic Code(s) accurately describing the patients diagnoses, symptoms, conditions, problems, complaints or other reasons for the outpatient visit a documented in the patients medical records; consults with treating physician on complex cases or if outpatient records are undocumented; requires thorough knowledge of ICD Coding.
  • Provide patient and telephone reception, check in/out, appointment scheduling and other department clerical duties as directed. Verifies eligibility, creates files, collects forms, and checks for legibility and completeness. Prepares schedules and provides personalized and professional patient/member service.
  • Establishes and maintains courteous and cooperative relations with the public, patients and other personnel.
  • May perform other duties as required.
  • Determine eligible coverage and add to patient account in correct filing order. Terminate any ineffective coverage
  • Verify account coverages have been updated by the system; if coverage has not been updated place stop bill on accounts and route to appropriate work queue or complete account correction Correct charges and errors for resubmission of claims
  • Correct clearinghouse/payer errors
  • Work designated HealthConnect work queues as assigned.
  • Assume other activities and responsibilities from time to time as directed.
  • Must be able to demonstrate the ability to work collaboratively with co-workers and supervisor and possess excellent organizational skills.
  • Must be customer service oriented.
  • Extensive contact with members, non-members, physicians, and third party administrators/carriers; requires excellent interpersonal skills.
  • Requires knowledge of automated billing system .
  • Requires knowledge of medical terminology, CPT procedure codes, anatomy and physiology to identify all billable services, including secondary medical conditions directly or indirectly related to the principle industrial condition being claimed or litigated by the patient
  • Requires thorough knowledge of ICD Coding.
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