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QA / UR / Case Management Jobs

Medical Audit Coord, RN Spec

Location: Oakland, California;

Job ID : 3641943

Description

Review claims for services obtained outside of Kaiser facilities for compliance with health plan service agreement with members; identifies health plan claims with potential quality of care issues, continuity of care problems, or access issues at medical facilities; and audits hospital billings on site at non-plan provider facilities and negotiates successful resolution of claim.

Essential Functions:
- Provides clinical expertise to other departments such as Workers Compensation, CSA/MSA outside case management in areas related to hospital and physician billing practices and cost containment activities.
- Works with legal department when indicated to resolve payment disputes.
- Serves as a consultant to CSA Continuing Care teams and case managers on issues on non-pricing, billing problems, procedures and benefit compliance issues. Identifies opportunities for cost containment. Works with regulatory compliance for review of benefit.
- Responsible for review ICD-9, CPT codes, medical records, UB-92 and HCFA forms and Kaiser Permanente internal systems (OTRS, Advice call logs). Determines if bills are payable or if additional informatio is needed, identification of potential fraud issues.
- Works with PRS staff as a resource for decision-making and medical terminology.
- Plans and organizes daily work to meet compliance timeframes. Provides feedback to manager to ensure work is within compliance.
- Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization.
- Acting with ethics and integrity, reporting non compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente's policies and procedures.
Qualifications: Basic Qualifications:
Experience
- Minimum five (5) years of clinical experience.
Education
- Graduate of an accredited nursing program required.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- Current RN license.

Additional Requirements:
- Must have demonstrated ability to work independently and make quick decisions with a high degree of competency utilzing multiple sources of information.
- Compentency in Microsoft Suites (Excel, Access, PowerPoint), excellent ability with proprietary, mainframe processing systems and KP technologies.
- Demonstrates strong understanding of medical terminology, ICD-9 coding, CPT coding principles.
- Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications:
- Minimum five (5) years of clinical experience in critical care preferred.
- Bachelor's degree preferred, OR four (4) years of experience in a directly related field.
- Certification or course completion certificates in coding preferred.
- The ability to make timely, sound decisions, and to act independently and negotiate successful resolution in difficult situations preferred.
- Familiarity with ICD-9 and CPT coding, hospital billing practices preferred.


Primary Location:California,Oakland,1800 Harrison 1800 Harrison

Scheduled Hours (1-40):40

Shift:Day

Working Days:Mon-Fri

Schedule:Full-time

Job Type:Standard

Employee Status:Regular

Employee Group:Salaried, Non-Union, Exempt

Job Level:Individual Contributor

Job:QA / UR / Case Management

Public Department Name:National Payment Integrity

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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