Claims Research Technician- DEPARTMENT ONLY

Company Name:
Kaiser Permanente
Investigates/researches paid claims that may have been processed incorrectly, either by system errors, contract changes or adjudicator errors and adjusts as needed. Makes members/patients/providers and their needs a primary focus of one's actions; develops and sustains productive member/patient/provider relationships. Actively seeks information to understand member/patient/provider circumstances, problems, expectations, and needs. Builds rapport and cooperative relationship with members/patients/providers, knowledge of provider contracts. Considers how actions or plans will affect members and providers; responds quickly to meet member/patient/provider needs and resolves issues.
Essential Functions:
- Processes CSF's and ISF's, Macess, Chats, SharePoint, Health Connect, DOI issues, Email's, review benefit exceptions, returned checks, student benefit claims, visiting member claims, self-funded claims reviews, accounting reviews, appeals, to include verifying information, spreadsheet knowledge, locating the necessary claim, determining how the claim was processed and adjusting the claim accordingly.
- Document processed claim information for the provider. Access web based applications such as Webstrat, and Code Review to verify correct pricing of claims. Make phone calls as needed.
- Conduct phone conferences to providers with management to determine correct outcomes of claims for adjustment or research.
- Assist management, appeals analysts, and provider relations analysts with claim questions.
- Process high dollar, and over limit claims and adjustments.
- Researches duplicate claims to determine if services were performed multiple times. If a duplicate claim was denied, researches the reason and adjusts the claim if supporting documentation exists.
- Ensures that corrected bills are received in a timely manner and adjusts as needed. If a formal appeal is attached or other relevant information, researches to ensure that it meets timely filing guidelines, and adjusts the claim.
- Researches services rendered and determines based on the location of services, and type of services, if the claim was denied correctly. If the claim was denied correctly, forward to appropriate staff for appeal review.
- Trains new staff as needed and tracks adjudicator errors while adjusting claims.
- Documents provider issues, processing corrected adjustments if applicable, and forwards to the Claims and Referrals Supervisor.
- Researches claims that have been denied . determine if the claim was denied correctly or resubmits for processing.
- Sorts Source 7's (e.g. foreign bills, dental, return to sender, etc.) researches to see if the claim is on file and sends back to be scanned or returns to appropriate area. Release claims due to Virtual Processing,
- Performs other duties as assigned by Management.
- Verify that claims finalized by adding check and remit numbers to spreadsheets. Research why claims have not paid correctly and follow-up with adjudication, eligibility, MABA, business configuration, Claims accounting or other departments as necessary. Verify benefits with the member's EOC in one-click.
- Adjusts claims with regard to a member's accumulations if the member has a cost share plan.
- Must prioritize and manage issues from multiple intake sources with flexibility with multiple management request, Build spreadsheets for SharePoint and DOI requests/complaints.
Basic Qualifications:
- Three (3) years of processing medical claims.
- One (1) year of claims research and adjustment processing experience.
- Two (2) years of experience working with claims systems.
- High School Diploma or GED required.
Licenses, Certifications, Registrations
- N/A.
Additional Requirements:
- Must have a thorough understanding of all aspects of medical claims processing, cob processing, dual Kaiser Plans Knowledge of cost share products, Commercial and Medicare.
- Experience must be on an automated system, including preparation of payments for medical bills, using medical terminology, CPT, ICD-9 (ICD-10) and UB92 coding for both Medicare and non-Medicare claims, creating multiple split claims with working knowledge of other insurance benefit plans including coordination of benefits,KPIC, no-fault and workers compensation, and manual processing.
- Effective communication skills required.
- 10 key by touch required.
- Personal computer terminal skills; windows based preferred.
- Must be able to work in a Labor Management Partnership environment.
- Demonstrate customer service skills, customer focus abilities and the ability to understand Kaiser Permanente customer needs.
- Score of 70% or greater for MS Excel Basic.
- Score of 70% or great for MS Word intermediate.
Preferred Qualifications:
- Claims processing and claims research and adjustment experience with Kaiser Permanente.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.

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