Job Description
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Role Description
- This role involves performing full scope of investigative and research functions associated with pre/post authorizations for member claims and referrals.
- Ensures pre-authorizations are complete and include pertinent data related to medical services and care received.
- Uses knowledge of Service Agreements and benefits in various KP markets within the CO region.
- Actively seeks information to understand claims and authorizations.
- Builds rapport and cooperative relationships with internal departments to ensure processing.
- This position requires compliance with all Kaiser Permanente quality, safety, and emergency policies and procedures.
- Demonstrates quality and effectiveness in work habits and clinical practice in every interaction.
- Ensures patient safety in the preparation and provisioning of care.
- Reports safety hazards, accidents, incidents, and unsafe working conditions promptly.
- Processes pre-payment authorizations using various systems including Macess, SharePoint, and Health Connect.
- Analyzes relevant data to determine approval or denial for member reimbursement requests.
- Partners with medical review to assess high dollar and over limit claims.
- Reviews daily queue production reports for Medicare and various Commercial plans.
- Handles appeals and escalated issues for members and providers.
- Participates in phone conferences with management regarding claims outcomes.
- Attends weekly meetings/calls regarding authorizations from CRC, mental health, and/or continuing care.
- Designs and delivers training sessions for CRC Referral Processors and new hires.
- Runs daily MACESS report and analyzes productivity metrics.
- Qualifications
- Minimum of three (3) years of healthcare experience in an inpatient/outpatient setting required.
- Minimum of six (6) months of experience researching and processing medical claims required.
- Minimum of six (6) months of experience doing referral/authorization entry required.
- High school diploma OR General Education Equivalency (GED) required.
- Requirements
- Thorough understanding of member claims and referral authorization processing.
- Knowledge of applicable insurance laws and regulations related to claims processing.
- Ability to read/interpret provider orders and apply medical coding procedures using CPT-4 and ICD-9.
- Understanding of medical terminology required.
- Knowledge of authorization roles for the entire Colorado region.
- Effective communication skills required.
- Personal computer terminal skills.
- Typing speed of 35 w.p.m with 5% or less error rate required.
- Demonstrated customer service skills and understanding of Kaiser Permanente customer needs.
Company Description
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