Description |
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 Provider appeals process from initial denial through the Board review decision. Actively participates in the Monthly Appeal Board meetings. Makes decisions on accuracy of processing & votes accordingly at the Board meeting. Maintains the DOI log & subsequent letters in 100% compliance of the Colorado State Appeals Law effective August of 2002.Communicates in an effective & constructive manner w/ all levels of personnel to ensure there is accurate & timely resolution to issues. Works equally well as an individual or in a team atmosphere w/ demonstrated skills in analytic problem solving in a sensitive environment. Maintains & supports a culture of compliance, ethics, & integrity in all Appeal processes. Demonstrated ability to identify & analyze inaccurate claims processing involved in Provider appeals. Develops & forwards recommendations & action plans based on Appeal findings & resolutions. Proficiency in team building, conflict resolution, group interaction, & facilitation is required. Maintains knowledge of policies & procedures & performs in accordance w/ applicable regulatory requirements, external laws as they relate to the appeals process ensuring all are maintained within company compliance.
Essential Functions:
- Researches & documents all pertinent appeal information available in multiple Claims systems areas such as, Qcare, Macess, Provider contracts & Membership
- Determines if all necessary information was present at time of processing; e.g. physician signature, timely filing & processing, proper coding, & authorizations obtained & applied
- Tracks the appeal type & volume w/ follow-up to immediate supervisor so additional training or performance issues can be addressed
- Posts all Board determinations to the DOI log by the end of the week the meeting took place
- Ensures all data relating to the Appeal request is scanned into the member's & provider's folder in Macess
- Ensures all internal policies & procedures for Provider Appeals are maintained w/ current & accurate information
- Provides written feedback on all Appeal Board meetings
- Assists the Training Administrator w/ duties as necessary
- For Essential Responsibilities 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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Requirements |
Basic Qualifications:
- A minimum of 3 years experience in a health claims processing environment w/ HMO, Medicare, Commercial & New products required
- Bachelor's degree or equivalent experience in Business Administration, Health Care Administration or related field
- Ability to research & analyze information based on appeal perspectives
- Exceptional knowledge base of Microsoft Word, excel, Business Objects & other software applications
- Excellent analytical & writing skills required
Primary Location: Colorado-Denver
Scheduled Hours (1-40): 40
Shift: Day
Working Days: Mon - Fri
Working Hours Start: 8:00 AM
Working Hours End: 5:00 PM
Schedule: Full-time
Job Type: Standard
Employee Status: Regular
Employee Group: Salaried Employees
Job Level: Individual Contributor
Job: Accounting, Finance and Actuarial Services
Public Department Name: Claims Admin
Travel: No
Job Eligible for Benefits: Yes
External hires must pass a background check/drug screen. We are proud to be an equal opportunity/affirmative action employer.
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