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Kaiser Permanente Careers

Insurance & Claims

Delivery You Can Count On

As a member of our Claims Connect team, you'll help process and deliver the claims information Kaiser Permanente's members, providers, regulators, and customers need, and expect, from a world-class health care organization.

Examiner Claims II

Location: Spokane, WA Job Number: 708675 Date posted: 06/14/2018
Description: Adjudicate post service Medicare, Commercial COB and Visiting Member claims, including all edits, manuual pricing and financial calculations for payment to providers or members. Answer phone inquiries from providers and internal customers regarding claims status or payment. Respond to requests for re-processing claims and make adjustments when appropriate. Perform analysis of GH checks and provider refunds. Respond to and identify technical and documentation issues from staff and work to resolve them. Help team members obtain a thorough understanding of claims processing. Work with manager or supervisor to analyze, resolve and communicate issues and resolutions to staff. Also responsible for the Kaiser A/P and A/R accounting functions.

Essential Responsibilities:
  • Accurate processing/reprocessing of claims for members including Medicare, Commercial, COB and Visiting Member claims using KFHPW processing procedures, provider manual agreements, fee schedules, pricing agreements & other resources to ensure that claims are processed correctly. Coordinate benefits with Medicare or other insurance carriers after establishing primary/secondary based on WAC and Medicare regulatory guidelines. Thorough understanding of Washington Administrative Codes (WAC) to ensure compliance guidelines are being adhered to within claims processing procedures for these units. Acts as a liaison between Claims and other departments under direction of supervisor/manager.
  • Responds to technical and documentation questions from staff as well as external customers. Recognize and communicate training needs of all staff within the unit to management. Train staff within the units on the departmental procedures, databases, software programs, and other training as needed.
  • Research and respond to escalated inquiries regarding claims payment issues. Recognize and communicate sytem and non system issues that are causing incorrect payment of claims.
  • Kaiser Visiting Member accounting functions to include: positng and reconciliation of payments in Kaiser database for the General Ledger. Request and post refunds from providers on incorrect payments. Run monthly billings and quarterly re-billings to the Kaiser regions.

  • Basic Qualifications:
  • Minimum five (5) years of claims experience AND a minimum three (3) years experience to include reprocessing claims.
  • High School Diploma/GED.
    License, Certification, Registration
  • N/A

    Additional Requirements:
  • Knowledge of claims processing or related system and processes.
  • Ability to identify resources to resolve issues; train a diverse workforce; troubleshoot in order to improve and promote quality; make technical and administrative decisions within specific guidelines.
  • Motivation, communication, analytical, problem solving and customer service skills.
  • Familiarity with the Washington Administrative Codes (WAC).

    Preferred Qualifications:
  • Bachelor's degree in business, health care, or management.

    Primary Location: Washington,Spokane,Admin. Center North Spokane 5615 W Sunset Hwy. Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Non-Union, Non-Exempt Job Level: Individual Contributor Job Category: Insurance / Claims Department: HMO Claims Travel: No
    Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    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 and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
  • About Insurance & Claims Careers

    Careers in Insurance & Claims

    Our insurance and claims teams are committed to meeting customer and member expectations when it comes to the timely and accurate processing of claims, while remaining in compliance with federal, state, and local laws, as well as regulations and rules. Make an impact as you contribute to the implementation of contemporary technology in areas such as claims quality, claims operations, business analysis, processing, configuration, reporting, and more.

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