Medical Audit Coordinator, RN Specialist

Description: Job Summary:

Review claims for services obtained outside of Kaiser facilities for compliance with health plan service agreement with members; identifies health plan claims with potential quality of care issues, continuity of care problems, or access issues at medical facilities; and audits hospital billings on site at non-plan provider facilities and negotiates successful resolution of claim.

Essential Responsibilities:

• Provides clinical expertise to other departments such as Workers Compensation, CSA/MSA outside case management in areas related to hospital and physician billing practices and cost containment activities.


• Works with legal department when indicated to resolve payment disputes.


• Serves as a consultant to CSA Continuing Care teams and case managers on issues on non-pricing, billing problems, procedures and benefit compliance issues. Identifies opportunities for cost containment. Works with regulatory compliance for review of benefit.


• Responsible for review ICD-9, CPT codes, medical records, UB-92 and HCFA forms and Kaiser Permanente internal systems (OTRS, Advice call logs). Determines if bills are payable or if additional informatio is needed, identification of potential fraud issues.


• Works with PRS staff as a resource for decision-making and medical terminology.


• Plans and organizes daily work to meet compliance timeframes. Provides feedback to manager to ensure work is within compliance.


• Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization.


• Acting with ethics and integrity, reporting non compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanentes policies and procedures.

Basic Qualifications:
Experience

• Minimum five (5) years of clinical experience.

Education

• Graduate of an accredited nursing program required.
• High School Diploma or General Education Development (GED) required.

License, Certification, Registration

• N/A

Additional Requirements:

• Must have demonstrated ability to work independently and make quick decisions with a high degree of competency utilzing multiple sources of information.
• Compentency in Microsoft Suites (Excel, Access, PowerPoint), excellent ability with proprietary, mainframe processing systems and KP technologies.
• Demonstrates strong understanding of medical terminology, ICD-9 coding, CPT coding principles.
• Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications:

• Minimum five (5) years of clinical experience in critical care preferred.
• The ability to make timely, sound decisions, and to act independently and negotiate successful resolution in difficult situations preferred.
• Certification or course completion certificates in coding preferred.
• Familiarity with ICD-9 and CPT coding, hospital billing practices preferred.
• Bachelors degree preferred, OR four (4) years of experience in a directly related field.

Primary Location: California,Oakland,1800 Harrison
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 08:00 AM
Working Hours End: 04:30 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: Individual Contributor
Department: Englewood MSSA Claims - National Claims Service Org - 0315
Pay Range: $118000 - $152680 / 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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