Performs telephonic advocacy services for members requiring assistance understanding their benefits, pre-certification requirements and provider network options. Essential duties include but not limited to benefit interpretation; evaluation and verification of eligibility; knowledge of in and out-of network physician and provider availability; understanding and assisting members to access care within Kaiser Permanente delivery system; processing and data entry of incoming pre-certification (telephonic or fax) requests; assist in preparing denial and non-coverage letters; advise members and /or providers of appeal and grievance process; quoting claims accumulators; interaction with physician's staff when incomplete information is received; and related clerical responsibilities related to member services.. Establish relationships and communicate with members, family, physicians and staff, inpatient and outpatient providers, case managers, utilization nurses, members service, claims, contract, benefits, appeals, risk and quality departments.
Essential Functions:
Provides telephonic member advocacy services for members requesting assistance in understanding their benefits, precertification requirements and provider network options.
Processes and performs data entry of telephonic pre-certification requests from members and providers.
Assists in the notification to members and providers of precertification approvals.
Performs intake and processing pre-certification reconsideration requests.
Assist members in understanding and accessing care within the Kaiser Permanente delivery system.
a. Facilitate appointment scheduling
b. Facilitate and obtaining/transferring of medical records
c. Facilitate and obtaining of test results
d. Provide clinic and provider locations and directions
Initiate calls and transfers to Kaiser Permanente Regional customer services, claims, pharmacy benefits, or other operations managers as necessary.
Telephonic inquiries from members and providers.
a. Member eligibility and benefit coverage
b. Claims and accumulators
c. Disease and/or case management
Identifies and refers potential cases for utilization management, case management, and disease management programs.
Assists in preparing denial and non-coverage member and/or provider letters.
Communicates denials and/or non-coverage services to members and providers.
Assists case managers and utilization nurses in follow-up calls to physicians, providers and/or members.
Interacts with physicians and staff and other healthcare providers as necessary to gather information as needed.
Assists Care Management Medical Director in outbound calls and assistant duties as needed.
Other duties as assigned.
Qualifications:
Basic Qualifications:
AA or AD College Degree
Five years of customer service and utilization operations experience in a hospital or insurance company setting.
Certification in medical terminology.
Excellent knowledge of CPT, ICD-9 and other related manuals/reference materials.
Experience with and understanding of Point-of-Service and PPO benefits, deductibles, co-pays and out of pocket financial responsibilities.
Excellent windows-based navigation skills, computer and fax skills.
Professional image and behavior.
Excellent organizational, oral and written communication, problem solving and decision making skills.
Good analytical skills.
Preferred Qualifications:
Two years experience in a Preferred Provider Organization.
Experience with URAC and/or NCQA accreditation process.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.