Kaiser Permanente Medical Claims Triage Specialist, Senior in Rancho Cucamonga, California

Review claims for services obtained outside of Kaiser facilities for compliance w/ health plan service agreement with members. Serves customers by adjudicating claims, completing audits, reviews covered losses, establishing proof of loss, overpayments, underpayments and other irregularities. Meets or exceeds defined quality levels. Demonstrated competency in coding, medical terminology, logical thinking and Microsoft Applications.

Essential Responsibilities: - Review SCAL/NCAL Foreign claims (no threshold amount). Research foreign claims to determine possible fraud and refer to Special Investigation Unit with appropriate supporting documents for review. - Follow Clinical Review Triage Process on all Med Audit queues in Legacy and Tapestry filtering unnecessary steps for RN's to process. - Identify Medi-Cal and Medicare members that are misidentified and/or living outside of the area and refer to CSC department for review. - Responsible for review ICD-9, CPT codes, medical records, UB-92 & HCFA forms & KP internal systems (OTRS, Advice call logs). Determines if bills are payable or if additional information is needed, if there are potential fraud issues. - Research operational issues, make recommendation, develop and implement solutions based on information from internal and external sources and clients. - Utilize the assigned technology platform to review, audit, and maintain functional databases and identify inconsistencies. - Assists in the training of new Provider Reimbursement Specialist and as resources to less experienced Provider Reimbursement Specialist. - Plan and organize daily work to meet compliance timeframes. Provides feedback to manager to ensure work is within compliance. - Identifies areas of special need for review or takes on additional review/projects as assigned by management. - Decisions are made to pay claims or refer to physician advisor based on clinical criteria related to emergency medical condition. - Uses independent judgment based on business related knowledge in deciding which claims should be paid and if any payment reductions are applicable. - Assigns work based on regulatory compliance, staffing, staff skill level & completing priorities. - Acting w/ ethics & integrity, reporting non-compliance, & adhering to applicable federal, state & local laws & regulations, accreditation & licenser requirements (if applicable), & KP's polices & procedures. - Resolve escalated issues that are routed to our Clinical Review via email and respond in a timely manner.

Qualifications: Basic Qualifications: Experience - Minimum five (5) years of related experience. Education - Associate's degreeOR two (2) years of experience in a directly related field. - High School Diploma or General Education Development (GED) required. License, Certification, Registration N/A

Additional Requirements: - Must have demonstrated ability to work independently and make quick decisions with a high degree of competency utilizing multiple sources of information. - Expert in MS Applications and KP technologies. - Excellent verbal and written skills. - Must be able to work in a Labor/Management Partnership environment. - Advanced knowledge of ICD-9 and/or CPT coding, Medicare rules application, DRG coding.

Preferred Qualifications:

  • Bachelor's degree in related field preferred, OR four (4) years of experience in a directly related field.
  • Ability to read Spanish.
  • Proficient in Excel.
  • Coding experience.
  • 10 years Claims experience.
  • Utilization Management experience.

COMPANY Kaiser PermanenteTITLE Medical Claims Triage Specialist, SeniorLOCATION Rancho Cucamonga, CAREQNUMBER 622991

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.