Kaiser Permanente Claims Authorization Processor in Aurora, Colorado
Performs full scope of investigative and research functions associated with pre/post authorizations for member claims and referrals. Ensures pre-authorizations are complete, information includes data pertinent to medical service and/or care received. Uses knowledge of Service Agreements and benefits in or Knowledge of different KP markets within the CO region. Actively seeks information to understand claims and authorizations. Builds rapport and cooperative relationship with internal departments to ensure processing.
Essential Functions: - Processes pre-payment authorizations, utilizing various systems, including, but not limited to: Macess, SharePoint, Health Connect, DOI issues, email's, review benefit exceptions, visiting member claims, selffunded claims reviews, appeals, to include verifying information, spreadsheet knowledge, locating the necessary claim, determining how the claim was processed&add authorization accordingly. Manually enters or updates authorization into XCELYS. Analyze all relevant data to determine approval or denial for member reimbursement requests including analysis of Out of Area and/or Urgent Care situations Partners w/ medical review to review&determine appropriateness of high dollar,&over limit claims&adjustments. Determine pre-authorizations for number of days&status (observation vs. inpatient) by reviewing the nature of the treatment&circumstances. If unable to make final determine/ outcome facilitate additional review by KP RN. - Review&work daily queue production reports for Medicare,&various Commercial plans, KPIC to decipher priorities based on date of service&aging. Understand different rules for various classifications. Reviews duplicate authorizations or units (i.e. PT, OT,&ST). Review cases to determine if benefit exception applies. - Appeals&escalated issues for members&providers: Receive CEP (customer experience portal) ticket number from SharePoint site, queue and/or e-mails regarding appeals&escalated issues. Pull claims from XCEYLS to determine what services were provided to member. Research&review member chart data from various systems (Health Connect, MACESS, etc.) to gather additional information. Make final determination. If necessary, create a CEP&ask them to reprocess for payment when physicians and/or mgrs are on site&in receipt of escalated issues. Researches services rendered&medical records&determines based on the location of services,&type of services, if the claim was denied correctly. If the claim was denied correctly, forwards to appropriate staff for appeal review or enters authorization to pay correctly if appropriate. Build spreadsheet for Share Point&DOI requests/complaints. - Participates w/ claims team on phone conferences w/ mgmt to determine correct outcomes of claims for adjustment or research. Assists mgmt, appeals analysts,&provider relations analysts w/ various claims inquiries. - Review Self-Funded authorization pending report to determine if authorization is on file or if not, follow authorization rules to determine if it is ok to add it or if determination cannot be made send info to Harrington Health requesting additional claim information. Daily review of the retro&concurrent term report to determine member's termination date&update authorization accordingly in Health Connect. Attend monthly self-funded meeting via WebEx&exchange feedback on authorization rules, updates on new groups, rules®ulations, etc. - On behalf of OPA Audits, attends weekly meetings/calls w/ claims, contracting,&business configuration regarding authorizations from CRC, mental health, and/or continuing care. Answer questions for adjudicators to assist w/ their audits. Determine corrective action for the error that was made to ensure it gets corrected&doesn't continue to occur in the future. - Design&deliver training sessions for CRC Referral Processors, new hires&temporary employees that work offsite in other states via WebEx. Consult w/ same groups to resolve daily issues as well. - Run daily MACESS report. Create&analyze excel report daily on productivity&circulate to mgmt&analytics areas for review. Breakdown individual productivity metrics by number of emails, sametime requests, CEPs, Macess, self-funded, logs, meetings,&other miscellaneous categories. Performs other job duties as assigned by mgmt.
Qualifications: Basic Qualifications: Experience - Minimum of three (3) years of healthcare experience in an inpatient/outpatient setting required. - Minimum of six (6) months of experience researching and processing medical claims required. - Minimum of six (6) months of experience doing referral/authorization entry required. Education - High school graduation OR General Education Development (GED) required. License, Certification, Registration - N/A.
Additional Requirements: - Must have thorough understanding of all aspects of member claims and referral authorization processing, applicable insurance laws and regulations and procedures related to claims processing, including Medicare, Medicaid, work comp and no fault. - Demonstrated ability to read/interpret provider orders and to apply medical coding procedures using CPT-4 and ICD-9. - Understanding of medical terminology required. - Knowledge of authorization roles for the entire Colorado region as well as VM, SF and KPIC. - Effective communication skills required. - Personal computer terminal skills. - Typing speed of 35 w.p.m. - Demonstrated customer service skills, customer focus abilities and the ability to understand Kaiser Permanente customer needs.
Preferred Qualifications: - N/A
COMPANY Kaiser PermanenteTITLE Claims Authorization ProcessorLOCATION Aurora, COREQNUMBER 616380
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.