Supervises, coordinates & evaluates the activities of personnel engaged in processing Claims & Referrals. Insures claims are accurately adjudicated & approved in accordance w/ departmental policies for the Rocky Mountain Region & Local Markets. 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:
- Supervises & coordinates the activities of personnel in the Claims & Referral Department
- Represents the organization's claims & referral process to include contract interpretation, implementation & compliance w/ Regulatory
Agencies eg, DOI, IRS, HCFA, NCQA
- Administers personnel policies & procedures w/ respect to counseling, disciplinary action & grievances
- Interviews, hires & evaluates department personnel
- Schedules & assigns work
- Approves time cards, vacations & other time off requests
- Evaluates & develops new & existing procedures, recommends & implements new procedures to improve operating efficiency & customer service
- 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
Qualifications:
Basic Qualifications:
- A minimum of 4 years of progressively responsible experience in a medical claims processing environment, including 2 years of supervisory experience
- Previous experience in an automated medical claims processing environment required
- bachelor's degree in business or health care or related field
- Equivalent experience will be considered
- Extensive knowledge of medical terminology, CPT-4 & ICD-9 coding
- Thorough knowledge of state, federal & Medicare regulations pertaining to claims processing
- Working knowledge of various health insurance products such as PPO, HMO, POS & indemnity
- Effective verbal, written & interpersonal skills are required
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.