Lead Research and Resolution Adjustor - MUST RESIDE IN COLORADO

-May be entitled to translation/bilingual, shift or other wage premiums as governed by the applicable collective bargaining agreement. Please refer to the respective collective bargaining agreement for additional information on such wage premiums: https://www.lmpartnership.org/local-contracts.

Job Summary:

Provides technical assistance to Research & Resolution Claims Adjustors. Participates in external and internal audits, provides training to new/current staff, and completes additional projects. Assist leadership by providing feedback on training and other assigned duties. Makes members/region and their needs a primary focus of ones actions; develops and sustains productive member/patient relationships. Actively seeks information to understand member/region circumstances, problems, expectations, and needs. Builds rapport and cooperative relationship with members/region. Considers how actions or plans will affect members; responds quickly to meet member/region needs and resolves problems.

Essential Responsibilities:

• Verify the intent of the inquiry: Utilizes knowledge of organizational policies and procedures to ensure adherence to contractual agreements and non-contracted pricing arrangements along with compliance with government regulations. Locate the necessary information relevant to the claim(s): Leverages information from the inquiry and using available resources. Proactive and or responsive outreach to provider, members and other customers that could include phone calls, emails or other methods as needed.

• Determine how the related claim(s) was originally processed. Research services rendered utilizing all available resources to determine if the claim was processed correctly. Research denied claims utilizing all information available to determine if the claim was denied correctly. Make organizational determination. Use the information gained in steps 1, 2 and 3 to review the original claim outcome and determine if an adjustment is warranted.

• Document determination: Development of a clear and concise case summary, which may be subject to review. Take appropriate next steps to resolve the inquiry (e.g., adjust claim related pends and holds, policy, benefit or contract update/review, CHATS, CRM, Call Center or other organizational area education or closure of issue with no further action).

• Apply research findings across a broader population of claims with similar issues (benefit, contract, membership, etc.). Provide input regarding training and educational opportunities that aid in improving upstream processing accuracy and outcomes, identifying error trends.Research returned Kaiser Permanente claims payment checks and classify the reason for their return.

• Work with claim systems and management to assign work. Attend and actively participate in meetings at request of management. Prepare HD claim submissions to ensure accuracy and timeliness. Effectively communicate with staff and management. Support the NCA training program by participating in training activities, answering claims related questions that staff raise, and serve as a subject matter expert relating to processes/procedures. May train as necessary.

• Other duties may be assigned within department job functions.

Basic Qualifications:

Experience

• Minimum five (5) years of medical claims in an integrated health plan environment adjudication experience (HMO, PPO, Indemnity environment). Which includes two (2) years of processing high complexity IE: Adjustments, transplants and high dollar.

Education

• High School Diploma or General Education Development (GED) required.

License, Certification, Registration

• N/A

Additional Requirements:

• Basic PC skills

• Working knowledge of Microsoft Word

• Ability to work in a Labor Management Partnership environment

• Customer service skills and the ability to understand Kaiser Permanente customer needs in a claims setting

• Ability to apply procedures, practices and methods used in claims processing.

• Ability to apply timely and accurate requirements of all state and federal regulatory guidelines.

• Ability to demonstrate complex problem solving and decision making.

Preferred Qualifications:

• Working knowledge of Microsoft Excel

• Demonstrated knowledge of medical terminology and international classification of Disease (ICD-10) and Current Procedure Terminology (CPT).

• AA degree, accounting or business related.

COMPANY: KAISER

TITLE: Lead Research and Resolution Adjustor - MUST RESIDE IN COLORADO

LOCATION: Denver, Colorado

REQNUMBER: 1455551

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.