Claims Admin Analyst
2 weeks ago
**Job Summary**:
The purpose of this position is to provide support to the Outside Medical Services department, Responsible for Coordinating and Processing Referrals in accordance with regulatory and organizational referral processing guidelines.Under direct supervision, Responsible for coordinating, resolving and communicating problems and issues between Medical Center physicians, Administration, Outside Providers and members in order to process and partner with the Medical Centers, Outside Providers and Claims Administration.
**Essential Responsibilities**:
- Reviews physicians requests for outside medical services.
- Verifies patient eligibility and contacts both outside facility and patient regarding billing procedures and appointment scheduling.
- Reviews and processes billings received from outside medical providers.
- Verifies authorized services prescribed, determines accuracy and appropriateness of charges.
- Determines whether questionable billings received are to be considered for payment through the outside medical referral system and reroutes billings.
- Follows up on referral compliance.
- Sets up and maintains files on all outside referral patients.
- Educates community hospital personnel, physicians and billing services regarding Kaiser Outside Medical referral and reimbursement policies and practices, covered benefits and authorized services.
- Interprets SCPMG, KFH and KFHP policies and answer inquiries from Kaiser Members, physicians and other involved personnel and support staff.
- Acts as liaison between Regional Offices and local Outside Referral desk to coordinate and implement all Outside Medical Systems for SCPMG associated with use of non-Kaiser facilities for the purposes of: in and out patient referrals, supplemental bed and pre-scheduled surgeries.
- Provide accurate information to outside providers and members to help facilitate most appropriate route of health care.
- Interpret and implement necessary procedures regarding contractual agreements between Kaiser Permanente and Community Hospitals and physicians.
- Performs other administrative duties as required.
- Follows cost avoidance policies and procedures by requesting LOAs on non-contracted referrals, Check passport, check W/C database, Check for CCS, and OIC information prior to processing referrals.
- Process and initiates NONC in accordance with plan rules and benefits.
- Performs daily review of I-file inquiries.
- Analyzes referrals and claims information for accuracy according to established guidelines and provides education/feedback and reports as applicable.
- Assists Claims Auditor with tracing sources of inaccuracies; reports and proposes remedial action to appropriate manager.
- Prepares detailed analysis of claims activity and submits reports/findings as requested.
- Carries out and maintains records of special processing payment adjustments/check requested.
- Works with Finance Department and others as resource regarding all aspects of Outside Medical Claims; researches and provides reports as requested.
- Reviews processing of outside medical payments on a continuous basis.
- Ensures safeguarding of assets through the verification of documentation, approvals and accurate coding of provider service and accounting data.
- Monitors and coordinates special transactions such as check adjustments and credits.
- Performs analysis of data entered for outside medical payments for the purpose of performance feedback.
- Performs special comprehensive reports as indicated or requested by management.
- Reviews, audits medical claims submitted by non-plan providers to ensure accuracy and appropriateness of charges submitted.
- Consults with clinical staff to determine medical necessity of procedures performed or care provided by a non-plan provider.
- Responds to provider appeals as it relates to disputed claims payment and authorized services.
- Determines if care provided corresponds to the charges submitted.
- Reviews appropriateness of CPT/ICD-9 coding.
- Identifies and coordinates contracting opportunities with problematic providers to decrease potential erroneous billing and promotes controlled outside medical cost.
**Basic Qualifications**:
Experience
- Minimum one (1) year of related work experience.
Education
- Bachelors degree in a health care related field OR four (4) years of experience in a directly related field.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- N/A
**Additional Requirements**:
- Familiarity with medical terminology required.
- Strong negotiation, conflict resolution and excellent interpersonal skills required.
- Strong analytical skills, excellent oral and written communication skills required.
- Proficiency in analyzing problems.
- Must have knowledge of regulatory requirements, policies and procedures development, and general expertise in areas that affect referral and claims processing.
- Must be able to work in a Labor/M
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