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Claims Adjuster

Primary Location Downey, California Schedule Full-time Shift Day Salary $37.04 - $41.03 / hour

Job Number 1363048 Date posted 07/02/2025

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Job Summary:

Reviews claims and makes payment and benefit determination. Conducts research as it relates to claims processing for medical appropriateness, and diagnosis, using ICD-9 codes and CPT codes as required.

Essential Responsibilities:

Reviews claims and makes payment determination with authorization limit to $9,999 per claim.

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

Checks with Lead and Supervisor for any claim exceeding $9,999.

Provides input to Supervisor regarding trends related to training, education to enhance department production and processes.

Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but limited to CMS, DMHC, DHS and requirements of accrediting agencies such as NCQA.

Proactively works to ensure claims are review & processed timely.

Basic Qualifications:

Experience

Three (3) to five (5) years Medical claims processing experience in a HMO/Indemnity environment including technical research and analysis experience.

Claims System OCPS; Windows NT; Word, Excel, Lotus Notes. Excellent skills in communication Medical Claims Processing.

CPT, ICD-9, Medical Terminology, COB/TPL/WC

Demonstrate ability to utilize Medical Terminology and International Classification

Diagnosis (ICD-9), HCPCS&CPT coding at a level appropriate to the job.

Education

High School Diploma/GED

License, Certification, Registration

Additional Requirements:

Preferred Qualifications:

Medical Terminology Certificate Preferred

Primary Location: California,Downey,Downey Boeing - Independence Park Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri, Working Hours Start: 08:00 AM Working Hours End: 04:30 PM Job Schedule: Full-time Job Type: Standard Worker Location: Remote Employee Status: Regular Employee Group/Union Affiliation: B01|SEIU|Local 399 Job Level: Individual Contributor Department: Independence Park - NCA Ongoing Operating Exp - 0315 Pay Range: $37.04 - $41.03 / hour Travel: No

Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.

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