Job Summary:
Performs full scope of investigative and research functions associated with pre/post authorizations for member claims and referrals. Ensures pre-authorizations are complete, information includes data pertinent to medical service and/or care received. Uses knowledge of Service Agreements and benefits in or Knowledge of different KP markets within the CO region. Actively seeks information to understand claims and authorizations. Builds rapport and cooperative relationship with internal departments to ensure processing.

Essential Responsibilities:

• This position, knows and complies with all Kaiser Permanente quality, safety, and emergency policies and procedures. Demonstrates quality and effectiveness in work habits and clinical practice in every interaction with patients, colleagues, providers, and leadership. Ensures patient safety in the preparation and provisioning of care related to but not limited to medications, procedures, infection prevention, fall prevention, including consistent use of two patient identifiers and procedural time outs. Reports safety hazards, accidents and incidents, and unsafe working conditions promptly.


• Processes pre-payment authorizations, utilizing various systems, including, but not limited to: Macess, SharePoint, Health Connect, DOI issues, emails, review benefit exceptions, visiting member claims, self-funded claims reviews, appeals, to include verifying information, spreadsheet knowledge, locating the necessary claim, determining how the claim was processed and add authorization accordingly. Manually enters or updates authorization into XCELYS. Analyze all relevant data to determine approval or denial for member reimbursement requests including analysis of Out of Area and/or Urgent Care situations Partners with medical review to review and determine appropriateness of high dollar, and over limit claims and adjustments. Determine pre-authorizations for number of days and status (observation vs. inpatient) by reviewing the nature of the treatment and circumstances. If unable to make final determine/ outcome facilitate additional review by KP RN.


• Review and work daily queue production reports for Medicare, and various Commercial plans, KPIC to decipher priorities based on date of service and aging. Understand different rules for various classifications. Reviews duplicate authorizations or units (i.e. PT, OT, and ST). Review cases to determine if benefit exception applies.


• Appeals and escalated issues for members and providers: Receive CEP (customer experience portal) ticket number from SharePoint site, queue and/or e-mails regarding appeals and escalated issues. Pull claims from XCEYLS to determine what services were provided to member. Research and review member chart data from various systems (Health Connect, MACESS, etc.) to gather additional information. Make final determination. If necessary, create a CEP and ask them to reprocess for payment when physicians and/or managers are on site and in receipt of escalated issues. Researches services rendered and medical records and determines based on the location of services, and type of services, if the claim was denied correctly. If the claim was denied correctly, forwards to appropriate staff for appeal review or enters authorization to pay correctly if appropriate. Build spreadsheet for Share Point and DOI requests/complaints.


• Participates with claims team on phone conferences with management to determine correct outcomes of claims for adjustment or research. Assists management, appeals analysts, and provider relations analysts with various claims inquiries.


• Review Self-Funded authorization pending report to determine if authorization is on file or if not, follow authorization rules to determine if it is ok to add it or if determination cannot be made send info to Harrington Health requesting additional claim information. Daily review of the retro and concurrent term report to determine members termination date and update authorization accordingly in Health Connect. Attend monthly self-funded meeting via WebEx and exchange feedback on authorization rules, updates on new groups, rules and regulations, etc.


• On behalf of OPA Audits, attends weekly meetings/calls with claims, contracting, and business configuration regarding authorizations from CRC, mental health, and/or continuing care. Answer questions for adjudicators to assist with their audits. Determine corrective action for the error that was made to ensure it gets corrected and doesnt continue to occur in the future.


• Design and deliver training sessions for CRC Referral Processors, new hires and temporary employees that work offsite in other states via WebEx. Consult with same groups to resolve daily issues as well.


• Run daily MACESS report. Create and analyze excel report daily on productivity and circulate to management and analytics areas for review. Breakdown individual productivity metrics by number of emails, sametime requests, CEPs, Macess, self-funded, logs, meetings, and other miscellaneous categories. Performs other job duties as assigned by management.

Basic Qualifications:
Experience

• 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.

Education

• High school diploma OR General Education Equivalency (GED) required.

License, Certification, Registration

• N/A

Additional Requirements:

• Must have thorough understanding of all aspects of member claims and referral authorization processing, applicable insurance laws and regulations and procedures related to claims processing, including Medicare, Medicaid, work comp and no fault.


• Demonstrated ability to read/interpret provider orders and to apply medical coding procedures using CPT-4 and ICD-9.


• Understanding of medical terminology required.


• Knowledge of authorization roles for the entire Colorado region as well as VM, SF and KPIC.


• 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, customer focus abilities and the ability to understand Kaiser Permanente customer needs.

Preferred Qualifications:

• N/A

Notes:

• Remote- On Call

PDN-9f3470a5-14f9-4304-a402-8525dd588a13