http://kpcareers.org/careers/insurance-and-claims-jobs en - Review, evaluate and screen Health Plan claims for completeness, accuracy and conformity to established policies and procedures.
- Make payment or denial decisions in accordance with policy and procedures of Health plan Claims Department.
- Authorize payments of claims in an amount based on authorization level guidelines.
- Review and evaluate complex claims involving Medicare, contracts, other insurance, workers' compensation, foreign claims and coordination of benefits.


Qualifications:

Qualifications:


Basis Qualifications:
- High School, GED
- 2 - 3 years of Claims experience in an automated claims processing environment.
- Excellent analytical skills.
- Must have the ability to make decisions in accordance with established policies and procedures and claims practices and work independently as required.
- Must possess knowledge of Medicare guidelines, data entry procedure, ICD-9, CPT 4 coding applications, medical terminology and claims practice.
- Thorough knowledge of claims processing terminology, equipment, procedures and practices.
- Must be able to establish and maintain effective working relationships with other employees, supervisors and the public.
- Must have considerable skills in analysis, interpretations, and application of procedures, practices and methods used in claims problem-solving and resolution.
- Must be able to meet the public and discuss claims issues and problems / complaints tactfully courteously and effectively.
- Must be able to work in a Labor / Management Partnership environment.


Skills Testing: Data Entry (10-key), Data Entry (Alpha- Numeric) 7000 keystrokes

]]> Wed, 16 May 2012 16:00:00 GMT 1994521-Oakland-Insurance-and-Claims Kaiser Permanente
Oakland, CA or Downey, CA

Subject matter expert representing Statewide Claims Operations for all aspects required to defend cases referred to the department by Legal.Support legal complaints and litigations by providing financial data and Claims analysis on open and closed cases.

- Partner with Kaiser Legal team on claim related court cases, litigations and intent to sue.
- Determine which documentation is relevant to cases received from Kaiser Legal and supply all requested documentation.
- Prepare advanced trend data analysis and reports pertaining to legal complaints and litigations. Performs ad hoc projects/studies of moderate scope utilizing data analysis skills.
- Provide root cause analysis driving reoccurring errors and rework through data analysis and auditing.
- Subject Matter Expert responsible for giving depositions on behalf of CCA. Give input, review and declarations.
- Develops and leverages relationships with peers, supervisors and management, both internal and external to CCA. Manages common resource demands and coordinate information relevant to legal cases between Northern CA and Southern CA for Statewide litigations and court cases.
- Preferred certification or advanced qualification by third party association that matches the function or field applicable to the business discipline.

Qualifications:

Basic Qualifications:
- Total of three (3) to five (5) years, to include two (2) or more years in a consulting role.
- Bachelor's degree in business/health care administration or related discipline.
- Preferred certification or advanced qualification by third party association that matches the function or field applicable to the business discipline preferred.
- Identifies and documents cross-functional and/or cross-divisional, functional requirements, workflow, information sources and distribution paths, and system/process specifications.
- Thorough knowledge of platforms of the assigned functional area.
- Coordinates installation and first-use of new applications/processes.
- Assists in developing test plans.
- Maintains current knowledge of application systems, interfaces, reporting processes, and data capture.
- Measures outcomes against an internal standard of excellence.
- Sets and works to meet challenging goals that will improve performance of project team or organizational unit.
- Assesses the needs of a job and objectively matches the strengths of a person to that job to ensure maximum performance and results.
- Listens actively and demonstrates sensitivity to patients/customers, encouraging them to discuss concerns, interests, needs, and difficult issues.
- Consistently monitors own work and seek further experiences to ensure continual quality patient/customer service and delivery.
- Monitors others' work to ensure quality and alignment in meeting member/customer needs; takes action to maintain standards.
- Prioritizes project work to meet member/customer needs.
- Takes initiative to alter normal procedures to meet specific member/customer needs.
- Consistently asks clarifying questions in order to understand the importance of assignments/projects in relation to operational unit goals.
- Prioritizes work in alignment with project objectives or goals.
- Recognizes linkages and understands impact of individual actions on other parts of the organization and the member/customer.]]> Tue, 15 May 2012 16:00:00 GMT 2433442-California-Insurance-and-Claims Essential Functions:
- Supervises administrative clerks and claims assistant, including the distribution of work, coaching, and performance evaluations.
- Acts as claims manager in the claims managers' absence.
- Reviews and approves work of examiners based on authority level.
- Trains claim examiners.
- Reviews, analyzes, and assigns new claims.
- Assigns claims for investigation as necessary to help resolve compensability issues.
- Makes determination to accept, delay, or deny claims based upon valid medical, factual, or statutory reasons.
- Controls and manages medical aspect of each claim.
- Determines probable monetary value of case and assigns appropriate reserves.
- Reviews reserves regularly to ensure adequacy.
- Ensures payment of benefits in accordance w/ the California Labor Code, Administrative Rules and Regulations, and departmental policies and procedures.
- Manages all aspects of litigated cases in accordance w/ client specifications.
- Assigns case to Rehabilitation Counselor as needed.
- Negotiates cost effective settlements.
- Meets w/ assigned clients at least quarterly to review claims and discuss any pertinent issues.
- Assumes managerial responsibilities in absence of claims manager.


Secondary Functions:
- Responsible for the daily management of workers compensation caseload of approximately 135 cases.
- Determines if a case should be accepted, delayed or denied based on medical, factual and legal aspects of each individual case.
- Controls and manages medical aspects of all cases in their caseload.
- Manages all aspects of litigation of negotiates settlements.

Qualifications:

Basic Qualifications:
- Significant experience (usually three (3) to five (5) years) in California workers compensation claims administration/examining.
- Previous supervisory experience or ability to act in a lead capacity.
- Bachelor's degree or equivalent experience in Business, Social, or Behavioral Science.
- Insurance Education Associations Certification and Certificate of Competency required.
- Strong written and verbal communication skills.
- Proficient in a variety of software applications.
- Must be able to work in a Labor/Management Partnership environment.



Preferred Qualifications:
- Minimum 5 years of workers compensation claims handling experience.
- Proven workers compensation claim technical expertise.


Skills Testing: Technical Workers Compensation Claim Exam]]> Thu, 10 May 2012 16:00:00 GMT 2424196-Oakland-Insurance-and-Claims
Essential Functions:
- Makes determination to accept, delay, or deny claims based upon valid medical, factual, or statutory reasons.
- Determines probable monetary value of case and assigns appropriate reserves; reviews reserves regularly to ensure adequacy.
- Assigns claims for investigation as necessary to help resolve compensabiltiy issues.
- Ensures payment of benefits in accordance with California Labor Code, Administrative Rules and Regulations, and departmental policies and procedures.
- Controls and manages medical aspects of each claim.
- Manages all aspects of litigated cases in accordance with client specifications.
- Assigns cases to rehabilitation counselor as needed.
- Meets with assigned clients at least quarterly to review claims and discuss any pertinent issues.
- Negotiates cost effective settlements.

Secondary Functions:
- Responsible for the daily management of a workers compensation caseload of approximately 135 cases.
- Determines if a case should be accepted, delayed or denied based on medical, factual and legal aspects of each individual case.
- Controls and manages medical aspects of all cases in their caseload.
- Determines probable monetary value of each case and assigns a reserve amount.
- Ensures payment of benefits in accordance with the California Labor Code and department policies and procedures.
- Manages all aspects of litigation and negotiates settlements.

Qualifications:

Basic Qualifications:
- Previous experience in a workers compensation claims administration, preferably as a claims assistant, claims examiner, or medical only representative, or workers compensation para-legal.
- Bachelor's degree, or equivalent experience in Business or Social Behavioral Science.
- Insurance Education Associations Certificate Program in Workers Compensation or equivalent required.
- Strong written and verbal communication skills.
- Proficient in a variety of computer software.
- Must be able to work in a Labor/Management Partnership environment.
- Proven workers compensation claim technical expertise preferred.


Skills Testing: Technical Workers Compensation Claim Exam]]> Mon, 07 May 2012 16:00:00 GMT 2320872-Oakland-Insurance-and-Claims
Essential Functions:
- Supervises assigned team members.
- Assists in hiring, training, and evaluating team members in assigned section.
- Provides coaching and mentoring to team members to enhance performance and development and promote team building.
- Identifies additional training needs and monitors performance against established indicators.
- Coordinates and communicates regularly with other supervisors to share information, best practices, systems issues, questions, training needs, and team performance status relative to process and quality standards.
- Provides recommendations and assists management with budget development process.
- Responsible for monitoring cost containment and quality standards.
- Participates in management team committees and task forces related to operations as assigned.
- Ensures compliance with government regulations including but not limited to those of HCFA, DOC, DHS and requirements of accrediting agencies such as NCQA.
- As necessary, assumes responsibilities of department during absence of manager.
- Claims: Assists in reviewing internal controls to ensure proper adjudication and payment of claims.
- Develops schedules to ensure proper staffing and production levels are maintained.
- Collaborates with Utilization Review, medical centers and other administrative staff in resolving benefit interpretation and validity of bill changes.
- May assist in claims analysis during high volume periods.
- Customer Service: Assists in developing call volume schedules to ensure proper staffing and production are maintained.
- May serve as liaison to the Customer Service Call Center in Corona.
- May respond to customer service calls during high volume call periods.
- Assists in monitoring customer service calls for quality assurance and staff performance and development purposes.


Qualifications:

Basic Qualifications:
- Minimum seven (7) years progressively responsible medical claims experience or comparable experience required.
- Three (3) years supervisory experience or demonstrated leadership ability required.
- Previous experience working as a member in a team environment preferred.
- Medical contracting and regulatory agency interface experience preferred.
- Bachelor's degree or equivalent work experience required.
- Master's degree in health administration preferred.
- Knowledge of various contracts required.
- Understanding of medical or clinical procedures required.
- Comprehensive knowledge of CPT, ICD-9, medical terminology, COB/TPL/WC required.
- Good oral, written, and interpersonal skills required.
- Knowledge of personal computer operations preferred.
]]> Sun, 06 May 2012 16:00:00 GMT 2408355-Los-Angeles-Insurance-and-Claims Essential Functions:
- Facilitate strong operational processes within operational departments to ensure Medicaid contractual and financial considerations are efficient, cost effective and compliant
- Requires oversight of all operational, administrative and reporting issues related to the Medicaid and Charitable Programs
- Establish business metrics and ongoing reporting against the metrics; the development of Medicaid, finance and compliance infrastructure to support the Medicaid/Special Populations business lines
- Negotiate, implement and oversight all Medicaid and Charitable Program contracts/MOU's for KPNW ensuring compliance with all provisions contained within each agreement
- Requires developing and maintaining relationships with leaders in each State Department and those in Community Benefit-sponsored organizations. Proactively anticipate and respond to state and federal initiatives which impact Medicaid, Community Benefit and KPNW
- With KP Finance and Actuarial, build and maintain a strong forecasting and costing system with strong metrics to guide decision-making
- Working with the Director, Medicaid & Charitable Programs, manage costs savings initiatives, reporting regularly based on agreed upon metrics
Secondary Functions:
- Participate in the development of a rolling multi-year strategy and business plan for Medicaid/Special Populations offerings that achieve overall strategic direction while using and investing resources appropriately
- Work includes working closely with Senior Leadership across Operations, HPA and Medical delivery to ensure alignment with organizational strategy and goals
- Directly supervise Medicaid & Charitable Product Administrator and Product Administrator, ensuring compliance with contract requirements, review and submission deadlines and required reporting


Qualifications:

Basic Qualifications:
- A minimum of 5 years of management experience in health care/insurance industry
- A minimum of 3 years of experience in product line management, marketing management or project management
- Bachelor's degree in business administration, public policy, health care administration or related field or equivalent combination of education and experience
- Ability to interpret and communicate laws and regulations related to health care and HMO's
- Experience in working with regulatory agencies and managing a large organization's response to actions
- Excellent verbal/written communication skills, strong negotiation skills
- Strong analytical and strategic planning skills
- Excellent public presentation skills
- Strong persuasive and interpersonal skills
Preferred Qualifications:
- Broad knowledge of KPNW or other health care organization
- Broad knowledge of current trends in health care delivery systems or carriers
- Knowledge of Medicaid laws and regulations
- Knowledge of Oregon and Washington legislative processes
- Strong marketing and sales background working with special populations and external customers
Salary Range:
$79,500 - $108,900
]]> Thu, 26 Apr 2012 16:00:00 GMT 2137415-Portland-Insurance-and-Claims Essential Functions:
- Revises existing EOCs (at least yearly, but more often as needed), prepares for filing with regulatory bodies, and creates new documents to support new products.
- Medicare Plan Benefit Package preparation and filing
- Revises Group Agreements (at least yearly) and works with Pricing and Underwriting to assure timely distribution to Groups.
- Maintains document production fields on BETS and assures availability of documents to internal customers via KP intranet site.
- Supports other positions within the department with document needs (i.e., PnPs, etc.).


Qualifications:

Basic Qualifications:
- A minimum of 2 years of experience with contract review and preparation.
- Bachelor's degree in business, health care administration, or equivalent work experience.
- Must possess the ability to read and interpret legal documents
- Analytical ability, problem solving skills, and ability to work independently required
- Ability to prioritize, attention to detail, and ability to deal with ambiguity required
- Must be computer proficient (Excel, Microsoft Word 2007)
- Must possess excellent verbal and written communication skills.
Preferred Qualifications:
- Certification in Microsoft Office suite of applications
- Experience with contract writing and /or policy/procedure development]]> Tue, 03 Apr 2012 16:00:00 GMT 2320873-Lakewood-Insurance-and-Claims Essential Functions:
- Partner w/ Sales & Account Management to create & execute a business plan that optimizes our opportunities across book of business.
- Produce accurate quotes in compliance w/ Underwriting & authority guidelines & state & federal laws for existing & prospective business.
- Develop & execute account &/or book of business plans to ensure attainment of goals primarily on complex cases.
- Conduct peer review including the most complex cases to ensure accuracy & appropriateness of quote.
- Partner w/ Sales & Account Management to create & execute a business plan that optimizes our opportunities across book of business.
- Produce accurate quotes in compliance w/ Underwriting & authority guidelines & state & federal laws for existing & prospective business.
- Develop & execute account &/or book of business plans to ensure attainment of goals primarily on complex cases.
- Conduct peer review including the most complex cases to ensure accuracy & appropriateness of quote.
- Manage business processes & policies that support optimal customer service.
- Meets established department turnaround goals by balancing deadlines.
- Designs new & interprets existing policies, procedures, & methodology.
- Develops & leads in the implementation of continuous quality improvement programs.
- Partner w/ & influence other internal customers to ensure KP business processes are in alignment w/ organizational goals.
- Ensure Underwriting is an integral partner in the creation of effective business solutions.
- Establish & leverage relationships w/ Sales/Account Management that optimize business potential w/ purchasers, brokers & consultants.
- Develop creative solutions that maximize credibility w/ customers & Sales/Account Management.
- Proactively acquire & exhibit knowledge of the external business environment to add value.
- Provide leadership to the team.
- Create & maintain positive, empowering work environment.
- Act as a role model.
- Coach & develop team members.


Qualifications:

Basic Qualifications:
- 5 years of progressive experience in rating, underwriting, marketplace evaluations, &/or financial analysis in a managed care environment or 7 years of quantitative analysis experience required.
- Bachelor's degree in mathematics, statistics, business administration, or a related field or applicable years of related work experience required.
Preferred Qualifications:
- Large group Underwriting preferred.
]]> Tue, 20 Mar 2012 16:00:00 GMT 2277338-Rockville-Insurance-and-Claims
Essential Functions:
- Analyzes & interprets benefit/plan related documentation, to include, but not limited to state & federal legislation
- Provides recommendations to implement & administer new/existing products & benefits considering customer, clinical, pricing & regulatory implications
- Documents benefit/plan requirements, creates, implements & maintains benefits/plans to meet regulatory & internal/external benefit administration needs
- Maintains & updates Benefit Administration systems/databases, e.g., web-based & legacy systems, w/ complex detailed benefit information to support products, benefits, membership, contracts, claims & care delivery
- Ensures benefit/plan information quality & compliance
- Develops & performs quality assurance processes
- Knowledgeable in all applicable Kaiser policies, local, state & federal laws & regulations, & accreditation standards
- Acts as a source-matter expert for benefits
- Troubleshoots benefit issues daily & recommends/implements solutions
- Interacts w/ a wide variety of internal customers to include, but not limited to Sales, Product Development, Underwriting, Contracts, Claims, & KP HealthConnect
- Data management through creation of spreadsheets & reports in Microsoft Excel & Access
- Helps design, develop & implement new & improved processes, tools & system enhancements
- Performs Project Lead role for Benefit Administration projects as needed
- Creates & manages project tasks & milestones as they relate to the Benefit Administration team
- Prepares training materials & communication updates & conducts training both in a group & 1-on-1 setting
- Assists w/ data validation, auditing & user acceptance testing
- Participates in regional or national projects as assigned
- Other duties as assigned
- In addition to defined technical requirements, accountable for consistently demonstrating service behaviors & principles defined by the KP Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives
- Also accountable for consistently demonstrating the knowledge, skills, abilities, & behaviors necessary to provide superior & culturally sensitive service to each other, to our members, & to purchasers, contracted providers & vendors

Qualifications:

Basic Qualifications:
- 3 years of work experience w/ benefit or claims administration/configuration/analysis required
- Bachelor's degree or equivalent experience in business or health care/insurance administration
- Strong detail & quality orientation essential
- Working knowledge of managed care, indemnity insurance, alternate funding, self funding, state, & federal regulations
- Excellent interpersonal & communication skills - verbal & written
- Self-motivated team player who can work independently w/ some management direction & who can work collaboratively w/ various stakeholders is required
- Strong problem solving & diagnostic skills required
- Strong process/work flow development & execution skills required
- Ability to adapt to constantly changing environments & priorities required

Preferred Qualifications:
- 1 year of business systems analysis/administration preferred
- Claims coding and/or adjudication experience helpful
- Proficiency in Microsoft Office Suite, advanced Excel skills preferred

Salary Range: $25.29 - $32.84 Hourly]]> Mon, 19 Mar 2012 16:00:00 GMT 2277332-Denver-Insurance-and-Claims Essential Functions:
- Acts as liaison between employees, employers, & workers compensation carriers & medical staff
- Coordinates appointments, referrals authorization, & communication regarding work restrictions, extended time off, need for further treatment, & vocational rehabilitation
- Provides continuity of care to patient by coordinating needed services & consultation, such as physical therapy, orthopedic surgery, etc
- Monitors patients progress at work & triggers review for work modifications
- Meets w/ employer/employee groups & workers compensation carriers to review, evaluate, & discuss specific problems & concerns per case management guidelines
- Makes provisions for offsite work process & job duty evaluations; makes recommendations to employers and employees with concerns regarding work-place hazards
- Collects data & prepares reports
- Assists in the development & presentation of educational programs for work-site health promotions
- Works w/ business office staff to assist in organization of authorization for care & efficient billing & other paperwork required by employers & insurance carriers


Qualifications:

Basic Qualifications:
- Minimum 2 years of experience to include coordinating return to work or modified work programs and/or ongoing contact with multiple, varied and local employer groups, workers compensation carriers and third party administrators.
- Experience developing procedures and policies
- Associate's degree and/or Insurance Education Certificate in Workers Compensation, Self Insurance Administrators Certificate and/or equivalent experience
- Bachelor's degree preferred
- Proven technical or academic knowledge in occupational health and/or workers compensation
- Ability to interface with employers and management in guiding them through complex regulatory and legal issues
- Team player with ability to manage a wide variety of projects simultaneously
- Excellent communication skills with emphasis on negotiations and problem solving
- Must be able to work in a Labor/Management Partnership environment
]]> Wed, 30 Nov 2011 14:00:00 GMT 1994540-Oakland-Insurance-and-Claims
The Claims Supervisor will assist in the management of approximately 15-40 Claims Adjusters. Provides guidance and support, serves as mentor and coach to team members in order to ensure operational efficiency and effectiveness. Develops goals, objectives, and career paths for team members. Assists in maintaining customer satisfaction by ensuring timely responses to inquiries and quick resolution of claims issues and concerns.-Accountable for results and metrics related to department operations.


Essential Functions:
- Supervises assigned team members. Assists in hiring, training, timekeeping, and evaluating team members in assigned section. Provides coaching and mentoring to team members to enhance performance and development and promote team building. Identifies additional training needs and monitors performance against established indicators.
- Coordinates and communicates regularly with other supervisors to share information, best practices, systems issues, questions, training needs, and team performance status relative to process and quality standards.
- Work closely with Labor Management Partners and attend required meetings.
- Provides recommendations and assists management with budget development process..
- Responsible for monitoring provider disputes, customer inquiries and quality standards.
- Provide assistance to the Operations, Rework & Intake Managers, as needed.
- Participates in management team committees and task forces related to operations as assigned.
- Ensures compliance and government regulations including but not limited to those of Medicare, Medi-cal & Commercial
- Assist in reviewing internal controls to ensure proper adjudication and payment of claims.
- Develops schedules to ensure proper staffing and production levels are maintained.
- Collaborates with Utilization Review, Medical Centers, and other Administrative staff in resolving benefit interpretation and validity of claim charges.
- May assist in claims analysis during high volume periods.
- Assist with all customer service issues with internal and external customers.

Qualifications:

Basic Qualifications:
- Bachelor's degree in Business Administration or a related field, or 4 years of related work experience
- Minimum5 years medical claims processing experience
- Minimum of 3 years supervisory and project management experience
- Ability to work in a Labor Management Partnership environment
- Thorough knowledge of claims administration
- Knowledge of various contracts
- Familiarity of coding protocols and terms
- Knowledge of claims regulations
- Understanding of medical or clinical procedures
- Knowledge of claims processing as it pertains to Medicare, Medi-cal & Commercial compliance regulations, and working knowledge of another functional area
- Proficient in the use of Microsoft Suite (Excel, PowerPoint, Word and Access)
- Excellent verbal and written communication skills

Preferred Qualifications:
- Experience interfacing with external regulatory agencies.
- Knowledge of claims processing systems]]> Tue, 27 Sep 2011 16:00:00 GMT 1793909-California-Insurance-and-Claims