Job Summary :
Under direct and indirect supervision, receive requests for referral to non-Plan medical services and inpatient admissions, review, triage or authorize requests for eligible Health Plan members according to departmental protocols and procedures;
communicate appropriate benefit information to Health Plan members and non-Plan providers; provide current information to NWP and other KP staff concerning contracted providers in the community and the relevant financial arrangement involved.
Accurately enter information from referral requests, authorized or denied, into HealthConnect (Tapestry) and the claims system (Diamond), accurately maintain inpatient census reports for alliance facilities.
Essential Responsibilities :
Analyze referral requests, ensuring they meet established departmental protocols. Authorize or triage referrals according to the RRC procedure manual, Provider Contracting agreements and Health Plan Service Agreements.
Initiate investigation with NWP on aberrant referral requests. Document activity related to the authorization or denial of requests.
Provide billing information to providers, including any vendor / non-Plan provider specific contractual information according to contractual arrangements, NWP protocols and RRC departmental policies and procedures.
Interpret maintain and utilize knowledge of HP benefits, contractual arrangements, NWP protocols and RRC departmental policies and procedures.
Prompt recognition of procedural defects or shortcomings in the total referral process; assist with the development of procedures that best utilize the resources of the organization.
Participate in committees and task forces as requested.
Review this information to determine if this admission has been directed by a Kaiser Permanente clinician, meets urgent / emergent criteria, determine if the services is authorized, advise the facility of authorization status and member benefits for the services requested.
Basic Qualifications :
Experience
Minimum three (3) years of previous work experience with in Kaiser Permanente Claims Administration, Health Plan or Clinical Operations or equivalent experience in related field.
This experience must demonstrate the use of coordination of skills, the ability to assimilate technical information and the ability to maintain effectiveness in a busy environment.
Education
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
N / A
Additional Requirements :
Preferred Qualifications :
Last updated : 2024-04-06
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