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 MD region. Salary ranges will vary for other labor markets outside of MD.

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.

Note: This job is the fully-qualified, career-oriented, journey-level position.

Essential Responsibilities:

• Performs data analysis on current reports (error reports, reviews trend analysis reports for accuracy, etc.).

• Audits complex medical claims payment data to validate conformance with specified coverage policies and payment methodologies.

• Audits complex High Dollar claims.

• Performs special project audits and reviews as requested by other departments and / or regions.

• Participates in the appropriate and approved training classes (in accordance with goals).

• Demonstrates awareness of work required at next level and working at that standard.

• Solves complex problems in creative, effective and professional ways in accordance with company objectives.

• Recognizes when the situation demands quick and immediate action and makes decisions quickly. Uses knowledge and expertise to make informed decisions.

• Builds productive working relationships internally and externally as well as networks with internal and external personnel in own area of expertise.

• Presents ideas assertively and directly influencing others to identified issues and concerns.

• Adapts ideas and ties them to the needs and goals of others to gain their support and commitment.

• Applies practical knowledge of internal and external regulatory processing guidelines, supports internal and external audits and mitigate any potential risk factors to the organization.

• Prepares and presents materials for QA error rebuttal meetings (e.g., SLR - Second Level Rebuttal).

• Conducts Audit-the-Auditor Quality Assurance audits and provides direct feedback.

• Assigns QA audit work with QA Supervisor/Manager.

• Prepares and distributes reports to Management and audit staff.

• Prepares and conducts On-the-Job Training, including new staff.

• Demonstrates good judgment in selecting methods and techniques to obtain solutions.

• Provides periodic informal work guidance/direction to, and training of team members.

• Provides performance input and recommendations to management for development/training plans.

  Basic Qualifications:

  Experience

• Requires a minimum of three (3) years of claims processing experience AND three (3) years medical claims auditing experience.

  Education

• Bachelors degree or four (4) 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 KP acceptability entity.

• Strong competency in MS Office Applications (Excel, Power Point and Word), excellent ability with proprietary, mainframe processing systems and KP Technologies.

• Possesses an outstanding ability with proprietary KP technologies (e.g., Tapestry).

• Internal candidates should meet or exceed performance metrics for 6 or more consecutive quarters.

• Articulates well the mission, vision and objectives within two or more major departments of operating units.

• Describes functions, key responsibilities and practices of multiple departments and units.

• Possesses a strong understanding and interpreting contracts and DLPs/P&Ps, knowledgeable with CPT coding, ICD-10, HCPCS coding, and possesses strong understanding of all pricing methodologies and benefit applications.

• Possesses a strong understanding of healthcare and health care delivery from either/both a payor or provider perspective, EDI and paper claim lifecycles.

• Knowledgeable and can support 1 - 2 KP regions.

• Listens actively and demonstrates sensitivity to staff members/customers, encouraging them to discuss concerns, interests, needs and difficult issues.

• Takes the next steps to help find solutions for team members (talk to supervisor, managers, etc.).

• Displays and expresses a genuine desire to help or serve others and meet their needs.

• Consistently monitors own work and seeks further experiences to ensure continual quality patient/customer service delivery.

• Engages in helping teams maintain focus on value-added services.

• Identifies gaps in customer expectations versus actual services levels.

• Follows up to verify client satisfaction and keeps customers informed. Presents ideas assertively and directly influencing others to identified issues and concerns.

• Adapts ideas well 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 AND four (4) years medical claims auditing experience preferred.

COMPANY: KAISER

TITLE: Senior Quality Medical Claims Auditor I

LOCATION: Hyattsville, Maryland

REQNUMBER: 1279286

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.