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    Senior Quality Medical Claims Auditor I - Hyattsville, United States - Kaiser Permanente

    Kaiser Permanente
    Kaiser Permanente Hyattsville, United States

    3 weeks ago

    Kaiser Permanente background
    Description
    : 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.
    Primary Location: Maryland,Hyattsville,New Carrollton Administration
    Scheduled Weekly Hours: 40
    Shift: Day
    Workdays: Mon, Tue, Wed, Thu, Fri
    Working Hours Start: 08:00 AM
    Working Hours End: 05:00 PM
    Job Schedule: Full-time
    Job Type: Standard
    Worker Location: Remote
    Employee Status: Regular
    Employee Group/Union Affiliation: NUE-PO-01|NUE|Non Union Employee
    Job Level: Entry Level
    Department: New Carrolltn Admin - Rgnl Facility Svcs Admin
    Pay Range: $ $88220 / year The ranges posted above reflect the location in the job posting. The salary range may vary if you reside in a different location or state than the location posted.
    Travel: No
    Remote: Work location is the remote workplace (from home) within KP authorized states. Worker location must align with Kaiser Permanente's Authorized States policy. At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.

    Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest
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