As a member of Kaiser Permanente Colorado's team, you'll be proud of the contributions you make every day. From our financial professionals and IT team members to our RNs and physicians on the front line of care-we work together to advocate the health and well-being of our members, colleagues, and communities. And we do it all in an environment known for breathtaking scenery. Maintaining a close relationship with the natural beauty that surrounds them, the cities of Denver, Boulder, Longmont, and Colorado Springs offer something for everyone-from historic districts to family neighborhoods to world-class ski resort trails. Prepare to be inspired.
Manages the Claims & Referral Department located in Denver, including referral processing, claims adjudication, claims research & resolution , & medical review of member & provider claims for outside referred & emergency medical services for Colorado Springs Commercial HMO, POS & PPO members. Partners w/ Insurance Systems to resolve Provider Issues. Accountable for creating a culture of compliance, ethics & integrity. Maintains knowledge of & assures departmental compliance w/ KP's Principles of Responsibility & policies & procedures, & applicable regulatory requirements & accreditation standards. Responds appropriately to observed fraud or abuse.
Essential Functions:
- Manages the Claims & Referral Department located in Denver, including referral processing, claims adjudication, claims research & resolution, claims, training & medical bill review of member & provider claims for outside referred & emergency medical services for Colorado Springs
- Develops & implements policies & procedures regarding claims & referral processing to support regulatory & business requirements for all products offered in Colorado Springs
- Manages to performance standards that comply w/ employer group, regulatory & market requirements
- Works in partnership w/ each market's provider contracting staff, utilization management staff & insurance systems to develop policies & procedures that support contract administrations & um protocols
- Maintain current information & knowledge of all applicable Kaiser policies, local, state & federal laws & regulations, & accreditation standards
- Ensures that the training activities incorporate all applicable KP policies, local, state & federal laws & regulations, & accreditation standards
- Supervises assigned staff
- This includes interviewing, selecting, training, motivating, evaluating, counseling, disciplining & terminating in compliance w/ EEO/AA goals & personnel policies of the organization
- 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
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