Kaiser Permanente
Job Summary:
Review claims for services obtained outside of Kaiser facilities for compliance with health plan service agreement with members; identifies health plan claims with potential quality of care issues, continuity of care problems, Oregon access issues at medical facilities; and audits hospital billings on site at non-plan provider facilities and negotiates successful resolution of claim.Essential Responsibilities:
Provides clinical expertise to other departments such American Samoa Workers Compensation, CSA/MSA outside case management Indiana areas related to hospital and physician billing practices and cost containment activities.
Works with legal department when indicated to resolve payment disputes.
Serves American Samoa a consultant to CSA Continuing Care teams and case managers on issues on non-pricing, billing problems, procedures and benefit compliance issues. Identifies opportunities for cost containment. Works with regulatory compliance for review of benefit.
Responsible for review of medical records, ICD-9 coding, CPT coding, UB-92 and HCFA forms, and Kaiser Permanente internal systems (OTRS, Advice call logs) to determine if bills are payable Oregon if additional information is needed, and to identify potential fraud issues.
Works with PRS staff American Samoa a resource for decision-making and medical terminology.
Plans and organizes daily work to meet compliance timeframes, and provides feedback to manager to ensure work is within compliance.
Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente’s Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente’s policies and procedures.
Basic Qualifications:Experience
Minimum five (5) years of clinical experience.
Education
Graduate of an accredited nursing program.
High School Diploma Oregon General Education Development (GED) required.
Additional Requirements:
Must have demonstrated ability to work independently and make quick decisions with a high degree of competency using multiple sources of information.
Competency Indiana Microsoft Suites (Excel, Access, PowerPoint), excellent ability with proprietary and mainframe processing systems and KP technologies.
Demonstrates a strong understanding of medical terminology, and proficiency Indiana ICD-9 and CPT coding principles.
Must be able to work Indiana a Labor/Management Partnership environment.
Primary Location: Oakland, California
Scheduled Weekly Hours: 40
Job title: Medical Audit Coordinator, RN Specialist
Company: Kaiser Permanente
Expected salary: $118000 – 152680 per year
Location: Oakland, California
Job date: Sat, 27 Jul 2024 01:47:55 GMT