The purpose of this position is to provide support to the Outside Medical Srvs Dept, Responsible for Coordinating & Processing Referrals in accordance w/regulatory & organizational referral processing guidelines. Under direct supervision, Responsible for coordinating, resolving & communicating problems & issues between Medical Center physicians, Admin, Outside Providers & members in order to process & partner w/the Medical Centers, Outside Providers & Claims Admin.
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Essential Functions:
- Reviews physician's requests for outside medical srvs.
- Verifies patient eligibility & contacts both outside facility & patient regarding billing procedures & appointment scheduling.
- Reviews & processes billings received from outside medical providers.
- Verifies authorized srvs prescribed, determines accuracy & appropriateness of charges.
- Determines whether questionable billings received are to be considered for payment through the outside medical referral system & reroutes billings.
- Follows up on referral compliance.
- Sets up & maintains files on all outside referral patients.
- Educates community hospital personnel, physicians & billing srvs regarding KP Outside Medical referral & reimbursement policies & practices, covered benefits & authorized srvs.
- Interprets SCPMG, KFH & KFHP policies & answer inquiries from KP Members, physicians & other involved personnel & support staff.
- Acts as liaison between Reg-l Offices & local Outside Referral desk to coordinate & implement all Outside Medical Systems for SCPMG associated w/use of non-KP facilities for the purposes of: in & out patient referrals, supplemental bed & pre-scheduled surgeries.
- Provide accurate information to outside providers & members to help facilitate most appropriate route of health care.
- Interpret & implement necessary procedures regarding contractual agreements between KP Permanente & Community Hospitals & physicians.
- Performs other administrative duties as required.
- Follows cost avoidance policies & procedures by requesting LOAs on non-contracted referrals, Check passport, check W/C database, Check for CCS, & OIC information prior to processing referrals.
- Process & initiates NONC in accordance w/plan rules & benefits.
- Performs daily review of I-file inquiries.
- Analyzes referrals & claims information for accuracy according to established guidelines & provides education/feedback & reports as applicable.
- Assists Claims Auditor w/tracing sources of inaccuracies; reports & proposes remedial action to appropriate Mrg.
- Prepares detailed analysis of claims activity & submits reports/findings as requested.
- Carries out & maintains records of special processing payment adjustments/check requested.
- Works w/Finance Dept & others as resource regarding all aspects of Outside Medical Claims; researches & provides reports as requested.
- Reviews processing of outside medical payments on a continuous basis.
- Ensures safeguarding of assets through the verification of documentation, approvals & accurate coding of provider srv & accounting data.
- Monitors & coordinates special transactions such as check adjustments & credits.
- Performs analysis of data entered for outside medical payments for the purpose of performance feedback.
- Performs special comprehensive reports as indicated or requested by Mgmt.
- Reviews, audits medical claims submitted by non-plan providers to ensure accuracy & appropriateness of charges submitted.
- Consults w/clinical staff to determine medical necessity of procedures performed or care provided by a non-plan provider.
- This job description is not all encompassing.
Basic Qualifications:
Experience
- Minimum one (1) year of related work experience.
- Bachelor's degree in a health care related field OR four (4) years of experience in a directly related field.
- High School Diploma or General Education Development (GED) required.
- N/A.
Additional Requirements:
- Familiarity with medical terminology required.
- Strong negotiation, conflict resolution and excellent interpersonal skills required.
- Proficient with software applications such as Word and Excel.
- Strong analytical skills, excellent oral and written communication skills required.
- Proficiency in analyzing problems.
- Must have knowledge of regulatory requirements, policies and procedures development, and general expertise in areas that affect referral and claims processing.
- Must be able to work in a Labor/Management Partnership environment.
Preferred Qualifications:
- Proficient with EPIC/Health and other software applications such as Word and Excel.
- Knowledge in Access database a plus.
PrimaryLocation : California,Los Angeles,4733 Sunset Annex
HoursPerWeek : 1
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri
WorkingHoursStart : 08:30 AM
WorkingHoursEnd : 05:00 PM
Job Schedule : Per Diem
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : NUE-SCAL-01|NUE|Non Union Employee
Job Level : Entry Level
Job Category : Insurance & Claims
Department : 4733 Sunset Medical Offices - Medical Office Admin Services - 0806
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.
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