Kaiser Permanente Outside Care Clinic Reviewer RN in Pasadena, California

Responsible for ensuring that Kaiser Permanente reimburses outside providers only for services that are authorized by physicians and that charges are reimbursed based on valid contractual agreements. For non-contracted/unauthorized services, ensures that charges for out-of-plan emergency situations are paid to reasonable and customary limits established by geographic area where services were rendered. Under established guidelines, the incumbent will provide problem resolution, either through independent action or recommendations to management to include: profiling of non-plan providers, utilization patterns, direct interaction with providers to discuss, review and query services provided, charges and/or expenses. Utilizes clinical experience to audit and perform in-depth financial analysis and trending submitted by non-plan providers to determine medical necessities, billing discrepancies, utilization and quality of care issues and benefit contract interpretation. The incumbent will serve as liaison between KFHP and Medical Group Service Area personnel.

Essential Responsibilities: - Reviews and audits professional and hospital bills submitted by non-plan providers to ensure accuracy and appropriateness of charges and services to include medical necessity, quality of care; interpretation of Health Plan benefits and contracts; DRG validations, desk level claim review, provider negotiations considering prior authorizations and specifications. - Identifies clinical criteria as defined by regulations and Medical Group to be applied in adjudication process. - Provides support and clinical expertise to claims and customer service staff regarding complex claims or referral issues. - Maintains resources by specialty of Medical Group physicians to assist in evaluation of complex, multiple surgical procedures. - Assures uniform interpretation by examiners of provider contracts and regulatory policies as they relate to reimbursement amounts and clinical edits. - Identifies clinical criteria as defined by regulation and Medical Group to be applied in adjudication process. - Ensures that geographically-specific conversion factors are updated to reflect percentile of reimbursement to current reasonable and customary allowances. - Assures that diagnoses, procedural, and provider records contain most current data for accurate claims adjudication. - Assists in testing and modifying system enhancements pertaining to clinical edits and reimbursement limits. - When necessary, assists in other functions performed by the Claims Administration Department, particularly with respect to insuring the competency of examiners.

Qualifications: Basic Qualifications: Experience - Minimum three (3) years of experience as a registered nurse (preferably Indemnity and/or HMO), demonstrating aptitude for clinical analysis, accurate and timely decision-making skills, and thorough understanding of reasonable and customary allowances. - Minimum two (2) years administrative/management and/or utilization experience in HMO setting. Education - Bachelor's degree in nursing License, Certification, Registration - Current Registered Nurse, CA license required.

Additional Requirements: - Selected individual must pass Medical Coding Certification examination within the first year of hire. - Good negotiation skills, excellent written and verbal communication skills. - Proficient in Microsoft Office applications. - Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications: - Medical Coding Certification ( CCS-P, CCS, CPC, RHIT and RHIA) preferred. - Comprehensive knowledge of coding methodologies (i.e., CPT, ICD-9, ICD-10, PCS, HCPCS). - Previous claim/bill auditing or contracting experience beneficial. - Knowledge of fraud and abuse prevention and understanding of compliance regulations such as Medicare, MediCal, DMHC, NCQA. - Familiarity with claim processing systems.

COMPANY Kaiser PermanenteTITLE Outside Care Clinic Reviewer RNLOCATION Pasadena, CAREQNUMBER 591972

External 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.