Claims Examiner, MUST RESIDE IN COLORADO

-May be entitled to translation/bilingual, shift or other wage premiums as governed by the applicable collective bargaining agreement. Please refer to the respective collective bargaining agreement for additional information on such wage premiums: https://www.lmpartnership.org/local-contracts.

Job Summary:

Through comprehensive assessment and analysis, adjudicates managed healthcare claims/bills, authorizations and referrals, for payment or denial within contract agreement and/or regulatory requirements. Performs these duties using industry standard knowledge of managed healthcare claim/bill payment processing and medical regulations, verifies and updates relevant data into various computerized internal and external systems.

Essential Responsibilities:

• For all lines of business analyze claim holds/pends, research and track required claim information to adjudicate professional and hospital claims/bills.

• Proactive and or responsive outreach to provider, members and other customers that could include phone calls, emails or other methods as needed.

• Proactively communicate with internal departments as appropriate to resolve claims issues promptly.

• Provides input to supervisor and training and development team regarding training and educational tools to enhance department production and processes.

• Proactively communicate with internal departments as appropriate to resolve claims issues promptly.

• Provides assistance to prepare materials as needed to the leads, supervisors and managers for external audits.

• Communicate problems and/or trends to leads and management. Understand and apply county, state and federal regulations.

• Other duties as assigned within department job functions.

Basic Qualifications:

Experience

• Minimum three (3) years of claims adjudication experience required.

Education

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

License, Certification, Registration

• N/A

Additional Requirements:

• Customer service experience.

• Basic PC skills required.

• Working knowledge of Microsoft Word.

• Ability to work in a in a Labor Management Partnership environment.

• Ability to understand and meet customer needs in a claims setting.

• Ability to apply procedures, practices and methods used in claims processing.

• Skills in analysis, interpretation and application of procedures, practices and methods used in claims adjudication without direct supervision or oversight.

Preferred Qualifications:

• N/A

COMPANY: KAISER

TITLE: Claims Examiner, MUST RESIDE IN COLORADO

LOCATION: Denver, Colorado

REQNUMBER: 1454858

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.