Experience with health insurance Claims adjudication, Disputes, Appeals and Grievances. Knowledge of existing regulatory guidelines and ability to interpret new requirements. Strong customer service background including critical thinking, written and verbal communication. Self-motivated, career-oriented problem solver with exception organizational skills. Job Summary:Supports data collection/interpretation by reviewing routine and non-routine data in claims databases, using working knowledge of KP systems. Following general instructions to collect medical data, validate medical coverage, and verify details in referral requests and/or authorizations and conduct an in-depth review of audit work, in accordance to policies and procedures. Acts in compliance with KP policies by informally mentoring others on compliance policy and maintaining working knowledge of relevant compliance standards, regulatory policies, laws, or accreditation standards. Follows general instructions to complete tasks during strategic projects and provides recommendations to improve specific process/system issues according to a variety of project metrics. Supports member identification/support processes by obtaining and providing uncommon information related to claims-payment issues and communicates with cross-team peers to understand resolutions that should be proposed to providers and members.Essential Responsibilities:
Pursues effective peer relationships within and across teams to obtain and share resources and information. Listens to, addresses, and seeks performance feedback; acts as an informal resource for less experienced team members. Actively seeks new relevant knowledge and skills based on strengths and weaknesses; reviews others work to help others learn. Adapts to change, challenges, and feedback with minimal guidance; demonstrates flexibility in work. Assesses and responds to the needs of others to support completion of work tasks.
Follows instructions to complete routine and non-routine work assignments with limited supervision. Collaborates with others to recommend appropriate solutions for routine and non-routine issues; escalates complex issues; communicates progress and information. Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities within ones team.
Supports the payment of claims as directed by: using judgement when gathering information to ensure that all expenditures are reviewed and paid on time in accordance with appropriate benefits and internal protocols with some support; and communicating with claims adjudicators and vendors to provide claims information (e.g. pay decisions, clinical determinations, referral matching) back to adjudicators on payment approval/denial, under a limited degree of supervision.
Acts in compliance with KP policies by: completing routine and non-routine tasks according to policies and procedures that support compliant work, under minimal guidance; conducting an in-depth review of work, providing feedback, and acting as an informal resource to ensure work is completed according to relevant documentation, policies, and processes related to referrals, authorization processes, utilization review; and utilizing working knowledge of relevant claims processing to identify relevant compliance standards, regulatory policies, laws, or accreditation standards that should be incorporated into compliance training.
Supports data collection/interpretation as directed by: utilizing working knowledge of database technologies to review and flag common and uncommon database issues related to system configurations and testing changes; conducting routine and non-routine data and documentation tasks to ensure the accuracy of claims details in claims databases across various regions; and following relevant processes and procedures to maintain database workflows.
Supports member identification/support processes as directed by: obtaining and reviewing uncommon information from cross-team peers to help resolve claims-payment issues or provider disputes; and communicating with cross-team peers to understand resolutions that should be proposed to providers and members when addressing claims and benefits inquiries.
Contributes to improvements to operations and technology processes by: gathering data on routine and non-routine billing errors and identifying problems with claims, referrals, or other system processes; and reviewing a variety of project metrics to monitor the success of strategic improvement projects.
Remote from any KP authorized state to include CA, OR, WA, CO, GA, VA, HI, MD & D.C.
Please Note: Salary ranges are geographically based, and the posted range reflects the Southern CA region. Lower salary ranges will apply for other labor markets outside of SCAL. Alternatively, higher salary ranges will apply for NCAL only.
Minimum Qualifications:
Minimum one (1) year of experience in referral experience which could be: Referral Services, Claims Membership, Claims Referral Processing, Authorization/Referral Claims Administration or a directly related field.
High School Diploma or GED, or equivalent AND minimum two (2) years of experience working in a corporate or business office environment OR Minimum three (3) years of experience working in a corporate or business office environment.
Additional Requirements:
Knowledge, Skills, and Abilities (KSAs): Insurance Coding; Data Entry; Customer Experience; Computer Literacy; Insurance; Insurance Regulations, Policies, and Procedures; Contract Review & Claims Validation; Health Insurance Products; Claims Applications
COMPANY: KAISERTITLE: Claims Operations Coordinator IIILOCATION: Pasadena, CaliforniaREQNUMBER: 1299902External 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.