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Medical Services Reviewer

Location: Aurora, Colorado;

Job ID : 3781620


Reviews and analyzes physician, hospital and technical service providers' billings in accordance with contracts and national/community standards in order to improve the quality of operations and to assure appropriate utilization of medical resources. Applies knowledge of clinical medicine, company contracts, policies and procedures in upcoding or unbundling of charges in avoiding over billing and improper payment. Works with health plan and medical group personnel to improve management of medical resources from a policy and procedure level. Maintain and support a culture of compliance, ethics and integrity. Responsible for ensuring ongoing compliance for Medical Review. Maintains knowledge of policies and procedures and performs in accordance with applicable regulatory requirements, external laws and accreditation standards as they relate to Medical Review. Makes members/patients and their needs a primary focus of one's actions; develops and sustains productive member/patient relationships. Actively seeks information to understand member/patient circumstances, problems, expectations, and needs. Builds rapport and cooperative relationship with members/patients. Considers how actions or plans will affect members; responds quickly to meet member/patient needs and resolves problems.

Essential Functions:
- Performs review, analysis and audit of physician, hospital and technical service billings. Reviews medical claims for appropriateness of care and medical necessity. Initiates communication and correspondence with physicians, hospitals, health care and technical service providers to insure that billings are in accordance with relevant contracts, standards, guidelines, provisions and procedures.
- Participates in establishing medical review policies and procedures and works with CPMG (UM/QA, EMS) to improve/change medical management of care.

Qualifications: Basic Qualifications:
- Minimum one (1) year of hospital bill audit, utilization management and/or provider relations experience.
- Minimum two (2) years of clinical experience.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- Licensure as a Registered Nurse or Certification as a Physician Assistant is required OR Licensure as a Practical Nurse with a minimum of two (2) years of clinical experience plus a minimum of five (5) years of claims supervisory/management experience may be substituted for the Registered Nurse or Certification as a Physician Assistant.

Additional Requirements:
- Demonstrated knowledge of medical billing and reimbursement procedures associated with providers in a managed health care contractual setting.
- Good verbal and written communication skills to work effectively with medical staff providers.
- Demonstrated customer service skills, customer focus abilities and the ability to understand Kaiser Permanente customer needs.
- Must be detail-oriented and have the ability to work independently.
- PC skills, including basic keyboard skills or the ability and willingness to learn needed computer skills.

Preferred Qualifications:
- Bachelor's degree preferred.

Primary Location:Colorado,Aurora,Waterpark II 2530 S. Parker Rd.

Scheduled Hours (1-40):40


Working Days:Mon - Fri


Job Type:Standard

Employee Status:Regular

Employee Group:Salaried, Non-Union, Exempt

Job Level:Individual Contributor

Job:Insurance / Claims

Public Department Name:Resource Stewardship

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
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