Claims Examiner Job Bakersfield area,California USA,Healthcare

Position: Claims Examiner I

KHS Buck Owens Office, Bakersfield, California, United States of America

Job Description

Posted Thursday, February 27, 2025 at 11:00 AM

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).

KHS reasonably expects to pay starting compensation for the position of Claims Examiner I in the range of $21.15 - 26.44 hourly.

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

Hybrid Position

Definition

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.

Distinguishing Characteristics

This position is responsible for claims auditing and payment functions for a Knox-Keene licensed health maintenance organization (HMO).

Essential Functions

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 over payment refund requests on SharePoint log.

Other Functions

Maintain productivity and quality in accordance with established guidelines.

Perform other job-related duties as required.

Adhere to all company policies and procedures relative to employment and job responsibilities.

Employment Standards

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.

Knowledge of:

Computerized online data entry systems; organizational structure of medical claims processing; medical terminology; HCPCS, CPT & ICD-10 coding, UB04 and CMS
1500 forms.

Ability to:

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

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

KHS Buck Owens Office, Bakersfield, California, United States of America

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