Description004302QualificationsUnder direct supervision, receives, reviews, prepares, and processes payments for authorized affiliated care services.
Self-audits work for timeliness and accuracy.
Meets established benchmarks.
Understands and maintains working knowledge of Health Plan benefits and applicable regulatory compliance requirements.
Participates in unit process-improvement activities.
Essential Functions:
, and notification of possible catastrophic claims.
Seeks interpretation from supervisor for questionable areas.
Does not release any payment for questionable services Operates
KPOPS
(Kaiser Permanente Outside Services Purchases System) according to established procedures.
accurately enters provide claim and organizational general ledger data Works collaboratively with other departments and staff to investigate claims with no referral on file.
Requests inpatient/outpatient records as necessary Assists with departmental mail distribution.
Copies, documents, and routes claims to appropriate personnel, including to other departments Analyzes claims received for accuracy, completeness, and eligibility for payment.
Notifies supervisor of large balances due to affiliated providers and any noticeable changes in charges Understands and maintains more than adequate knowledge of Kaiser Health Plan benefits, services and impending changes.
Demonstrates ability to apply benefits and correctly adjudicate claims based on benefits and contractual agreements Understands and maintains general working knowledge of Organization's accounting (general ledger) system.
Runs batch and month-end reports to self-monitor efficiency and accuracy.
Follows established unit policies and procedures to make corrections to
KPOPS
Prepares and sends letters and other written communication to members/clients as directed and required by work scope.
Requests refunds from providers when appropriate Receives and/or places telephone calls to obtain/provide necessary information.
Takes messages or routes calls to appropriate entity/individual Works collaboratively with appropriate/designated
HLM
and unit staff to ensure that authorized services are identified and registered and appropriately accrued into
KPOPS
within established pre-service timeframes Interprets and explains policies, procedures, and Health Plan benefit issues related to specific requests for referrals or payment to
HPMG
physicians, other Kaiser Permanente staff and management, patients and affiliated providers.
Seeks assistance from manager as indicated Identifies potential quality and utilization management issues and reports them to manager.
Documents questionable use of Health Plan benefits and/or inconsistencies in application and reports to manager.
Identifies trends/issues in affiliated provider billing and reports to manager Meets departmental performance issues Participates in unit process-improvement activities, including but not limited to self-audits, benchmarking studies and process reengineering