Under direct supervision, maintains current records of all physician outside referrals of KP Health Plan members, verifies that outside referrals have proper authorizations for prescribed services, monitors expenditures to determine appropriateness of payment per established guidelines, & sets up reporting systems for the processing of forms required for outside referrals & the payment of outside services rendered.
Essential Functions:
- Reviews physician's requests for outside medical services
- Verifies patient eligibility & contacts both outside facility & patient regarding billing procedures & appointment scheduling
- Reviews & processes billings received from outside medical providers
- Verifies authorized services prescribed, determines accuracy & appropriateness of charges
- Determines whether questionable billings received are to be considered for payment through the outside medical referral system & reroutes billings
- Follows up on outstanding accounts
- Sets up & maintains files on all outside referral patients
- Sets up files on all no-bed patients & pre-scheduled surgeries, notifies patients & outside providers & processes invoices
- Educates community hospital personnel, physicians & billing services regarding Kaiser Outside Medical referral & reimbursement policies & practices, covered benefits & authorized services
- Interpret SCPMG, KFH & KFHP policies & answer inquiries from Kaiser members, physicians & other involved personnel & support staff
- Act as liaison between Regional Offices & local Outside Referral desk to coordinate & implement all Outside Medical Systems for SCPMG associated w/ use of non-Kaiser facilities for the purposes of: in & out patient referrals, supplemental bed & pre-scheduled surgeries
- Provide accurate information to outside providers & members to help facilitate most appropriate route of health care
- Interpret & implement necessary procedures regarding contractual agreements between KP & Community Hospitals & physicians
- Performs other administrative duties as required
Qualifications:
Basic Qualifications:
- High School Diploma/GED.
- One (1) to three (3) years of related work experience required.
-Knowledge and experience with various computer programs.
- Good communication and interpersonal skills as well as mathematical skills.
- Medical terminology and knowledge of Medicare Guidelines preferred.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.