Job Summary:
Remote from any KP location in CA, OR, CO, WA, GA, MD, VA, HI or D.C. Only.
** PLEASE NOTE: Salary ranges are geographically based and the posted range reflects the Southern CA region. Applicable salary ranges will apply for other labor markets outside of SCAL.
Quality Claims Auditor: This position exists to ensure the integrity of medical payments for the organization through verification of the accuracy of data-entered information and by auditing service related information and invoice adjudication/payment for compliance with contract terms and Department/Regional policy and procedures.
The auditor must be proficient with the medical systems, claims processing and adjudication. The position requires research, problem resolution and specialized knowledge in the areas of benefits, contracts, Medicare, Medicaid, Coordination of Benefits and Third-Party liability, WebStrat, Multiplan, Beechstreet and other pricers.
Essential Responsibilities:
Conducts quality assurance audits for all Lines of Business.
Conducts quality assurance audits for claim adjustments, refunds and provider disputes.
Performs routine and moderately complex claim audits for payment accuracy in accordance with regulatory standards, and business policies.
Participates in some special projects/work.
Participates in the appropriate and approved training classes during year (in accordance with goals).
Demonstrates awareness of work required at next level and working at that standard.
Works on problems of moderate scope where analysis of situations and / or data requires review of variety of factors.
Exercises good judgment within defined procedures and practices to determine appropriate action.
Builds productive working relationships internally and externally.
Presents ideas assertively and directly, providing data to support conclusions.
Adapts ideas and ties them to the needs and goals of others to gain their support and commitment.
Applies knowledge of internal and external regulatory processing guidelines.
Basic Qualifications:
Experience
Requires a minimum of three (3) years of claims processing experience OR two (2) years medical claims auditing experience.
Education
Associates degree or two (2) years of directly related experience.
High School diploma or General Educational Development (GED) required.
License, Certification, Registration
N/A
Additional Requirements:
Must be able to work in a Labor-Management Partnership environment.
Certification in medical terminology from an acceptable entity is preferred.
Intermediate competency in MS Office Applications (Excel and Word).
Strong ability with proprietary and mainframe processing systems KP technologies (e.g., Tapestry) is preferred.
Internal candidates should meet or exceed performance metrics for 5 or more consecutive quarters.
Able to discuss mission, vision and objectives within own department and unit.
Describes company philosophy, culture and history.
Discusses the roles and responsibilities of major business units and departments operating principles and practices.
Able to identify and discuss key players, key issues and strategies.
Understands and Interprets contracts and DLPs/P&Ps, knowledgeable with CPT coding, ICD-10, HCPCS coding, various pricing methodologies and benefit application.
Possesses a good understanding of healthcare benefits and health care delivery from either/both a payor or provider perspective, EDI and paper claim lifecycle.
Listens actively and demonstrates sensitivity to staff members/customers, encouraging them to discuss concerns, interests, needs and difficult issues.
Works effectively in teams to achieve common goals.
Monitors own work and seeks further experiences to ensure continual quality patient/customer service delivery.
Identifies and discusses client expectations as relevant to own area.
Monitors and reports on delivery of what was promised.
Conducts and analyzes daily problems for trends and take steps to avoid recurrence.
Puts forward ideas assertively and directly, providing data to support conclusions.
Adapts ideas and ties them to the needs and goals of others to gain their support and commitment.
Clearly communicates using verbal and written methods.
Preferred Qualifications:
Four (4) years of claims processing experience preferred.
#J-18808-Ljbffr
