Senior Medical Audit Coordinator RN (Oakland CA) Oakland, CA
Kaiser Permanente
Medical Audit Coordinator
Oakland, CA
The Medical Audit Coordinator reviews claims for services obtained outside of Kaiser facilities for compliance with health plan service agreement with members; identifies health plan claims with potential quality of care issues, continuity of care problems, or access issues at medical facilities; and audits hospital billings on site at non Plan provider facilities and negotiates successful resolution of claim.
Essential Functions:
- Provides clinical expertise to other departments such as Workers Comp., TPMG referrals, CSA/ MSA outside case management in areas related to hospital and physician billing practices and cost containment activities.
- Works with legal department when indicated to resolve payment disputes.
- The Medical Audit Coordinator serves as a consultant to CSA Continuing Care teams and case managers on issues of non-Plan pricing, billing problems, procedures and benefit compliance issues. Identifies opportunities for cost containment. Works with regulatory compliance for review of benefit.
- Responsible for review of ICD-9, CPT codes, medical records, UB- 92 and HCFA forms as well as Kaiser Permanente internal systems (OTRS, Advice call logs). Determines if bills are payable or if additional information is needed.
- Works with PRS staff as a resource for decision-making and medical terminology.
- Plans, organizes daily work to meet compliance timeframe's. Provides feedback to manager to ensure work is within compliance.
- Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization.
- Decisions are made following State and Federal regulations related to provider reimbursement for claims, NCQA standards, Kaiser internal policies related to payment of out of Plan services.
- Determines whether to pay claim or refer to an advisor based on clinical criteria related to emergency medical condition.
- Payable claims are analyzed for correct contract interpretation, Medicare fee schedule interpretation, correct coding.
- Analyzes information from multiple internal and external sources when reviewing a claim episode of care.
- Assigns work based on regulatory compliance, staffing, staff skill level and competing priorities
- The Medical Audit Coordinator serves as a consultant to CSA Continuing Care teams and case managers on issues of non-Plan pricing, billing problems, procedures and benefit compliance issues.
- Works with interregional counterparts for matters of billing resolutions and clinical issues and with regulatory department regarding issues of compliance and interdepartmental review of benefit issues
- Independently prioritizes work on hand based on compliance.
- Expected that this position possess the ability to work with minimal direction from supervisor.
- Has the authority to direct the work of others such as Project Analyst, to meet compliance dates.
Qualifications:
Basic Qualifications
- Graduate of an accredited Nursing Program.
- Current California RN license is required.
- 5+ years clinical experience, preferably in critical care.
- Ability to make timely and sound decisions, and act independently and negotiate successful resolution in difficult situations.
- Proficient in the use of MS Applications (Excel, Access, Power Point), excellent ability with proprietary, mainframe processing systems and KP Technologies
- Demonstrates understanding of medical terminology, ICD-9 coding, CPT coding principles
- Knowledge of LMP required.
- Strong customer service skills
- Must understand DHS, Medicare, ERISA guidelines for payment of claims
- Knowledge of state regulations pertaining to member and provider appeals rights required
Qualified candidates must have the following skills:
- Takes Accountability
- Communicates Effectively
- Focuses on the Customer
- Collaborates
- Drives for Results
- Business Acumen
- Makes Effective Decisions
- Solves Problems through Planning & Analysis
- Pays Attention to Detail
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