Under direct supervision maintains current records and processes all physicians outside referrals for Health Plan members, verifies that outside referrals have proper authorizations for prescribed services, and reviews and processes invoices for payment per established guidelines. Communicates w/ outside providers, patients and staff regarding policies, and sets up reporting systems for the processing of forms required for outside referrals and the payment of outside services rendered. Processes Durable Medical Equipment (DME) for members, assists members, verifies eligibility and obtains physician's prescriptions as required, processes invoices per their health plan benefit, and performs related clerical duties as required.
Essential Functions:
- Receives reviews and/or researches physician's requests for outside referral for proper completion and authorized approvals, confirms if prescribed outside services are covered by contract, verifies eligibility.
- Processes referral to administration for final approval.
- Enters referrals/orders onto computerized regional database.
- Notifies outside hospitals and providers regarding physician's orders for treatment and limitation on services rendered to referred patients.
- Schedules patients for outside referral services in accordance with authorized physician orders and patient's eligibility per contract.
- Informs patients of appointment times for prescribed procedures, including physician's instructions.
- Follows up with Kaiser Permanente physicians to obtain results of outside referral tests and results of diagnostic evaluations.
- Audits bills (as needed) for outside referral services, verifies authorized services prescribed, and determines appropriateness of charges by researching CRVS (CA relative value source) codes, consulting with Chief and/or Assistant Chief of Service as required, and determining whether contract rates apply per established guidelines.
- Consults with Manager and/or Health Plan representative regarding entity payment divisions for outside referral charges wherever outside services relate to more than one entity.
- Codes bills with appropriate cost center/expense codes per regional system protocol. Verifies charges billed against reasonable and customary guidelines, contracts and RBRVS.
- Sets up and maintains various computerized and manual ledgers, logs and file systems to collect information required for financial allocation and statistical data.
- Works with analysts in Accounts Payable and General Accounting and Claims Administration Department to ensure accurate posting in the in the general ledger by cost center and expense code.
- As requested, identifies unpaid expenses for year-end accrual accounts, as well as monthly accruals.
- When required, calls outside physicians and/or hospitals whenever charges billed do not correspond to prescribed services, CRVS rates, or contractual agreements, and requests that bills be reissued per appropriate authorized services/CRVS rates.
- Follow up, as necessary, with outside physicians, laboratories, medical office group practices, and hospitals to secure proper itemization of services required for payment of statement of charges.
- Provides statistical reports to MSA Medical Director or his designee and department chiefs on referral providers, number of outside procedures, costs per procedures and other related data.
- Assume other activities and responsibilities from time to time as directed.
Qualifications:
This is a repost of 165242.
Basic Qualifications:
- Bilingual (English/Spanish) Level I required
- Experience w/ invoice processing and billing systems (Preferred)
- Experience w/ ICD 9, CPT, RBRVS, HCPCS, DRG coding
- Work experience in a medical office setting
- Must have formal Medical Terminology training with certificate or have ability to pass standard test
- Must type a minimum of 40 wpm. Typing must be current within one (1) year. Please contact Human Resources for testing.
- Good accounting knowledge (Preferred)
- Excellent communication, language, & writing skills, as well as demonstrated speed & efficiency in typing & in the utilization of other office equipment (Preferred)
Notes:
- This is a Full-time, variable position between the hours of: 8:00 am - 8:00 pm.
- Schedule may include working rotating weekends
- Must successfully pass or have passed the bilingual test (within the last 12 months), or be active in the QBS program.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.