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Experience:
No experience
Employment Type:
Intern/Co-op
Posted:
8/5/2015
Job Category:
Health Care Provider
Industry:
Health Care & Medicine
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Claims Quality Auditor Sr
Kaiser Permanente | Sacramento, California
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Job Description

Quality Claims Auditor: This position exists to ensure the integrity of outside medical payments for the organization through verification of the accuracy of data-entered info & by auditing srv related info & invoice adjudication/payment for compliance w/contract terms & Dept/Regl policy & procedures. The auditor must be thoroughly familiar w/outside medical systems & claims processing/adjudication processes. The Auditor must independently perform comprehensive audits of claims to source documents & identify inaccuracies. Conduct quality audits of claims, pre & post payments, utilizing appropriate sources of info, including eligibility, enrollment, provider contracts, policy & procedures. The position requires research, problem resolution & specialized knowledge in the areas of contracts, Medicare & Medi-Cal regulations & reimbursement rules, Multiplan & Beechstreet, Worker's Compensation, Coordination of Benefits & Third Party liability. The auditor must also be capable of developing a working relationship w/regulatory agencies. The level of involvement depends on the specific location. Ensures timely intervention into the srv quality issues in order to enhance srv delivery & customer satisfaction.

 

Essential Functions:
Participate in appropriate & approved training classes during year (in accordance w/goals). Conduct COC training for the WC Auditors. Cross train Oakland Auditors on various NCAL audits. Provide system &/or claim training for internal & external Audit entities (SOX, AON, etc.) As needed, train other teams & Depts.
Data analysis on current reports (error reports, review trend analysis reports for accuracy, etc). Provide analysis on errors identified in the OPA, SOX & AON audits by determining the root cause for each error reported.
In-srvs staff members on new & existing policies & procedures. Active member on the Policy Statement team. Collaborate on new error codes or policy statements. Participate in the training &/or communication of the updates after Core team approval.
Conduct Audit-the Auditor Quality Assurance.
Supervise & distribute the QC tool work w/QA Supv. Prepare & distribute reports to Mgmt, HPRS, NCO,&Internal Audit staff.
Run the unassigned inventory reports from the QC tool weekly & distribute the audits to the Auditors in Oakland & WC. Redistribute work in the QC Tool as needed. Provide CCA Compliance, QA & Operations Mgmt w/outstanding audits, denial, OPA accuracy, overpayment & underpayment reports throughout the month.
Prepare & conduct OJT schedule.
Prepare & present material for CQI meetings.
Broad application of principles, theories, & concepts in applicable discipline, plus working knowledge of other related fields. Implement the Continuum of Care audit process & the trainee new hire audit process. Work w/HP & TPMG auditor to align the co-payment process w/the Continuum of Care audits. Train the auditors & assist the training Dept w/the training material.
This job is the fully-qualified, career-oriented, journey-level position.
Works on problems of diverse scope where analysis of data requires evaluation of identifiable factors.
Awareness of work required at next level & working at that standard.
Provide feedback for the operations team, auditors on the identifiable factors.
Demonstrates good judgment in selecting methods & techniques for obtaining solutions.
Networks w/Sr internal & external personnel in own area of expertise. Network w/systems, training, finance, contracting, operations, compliance & other teams to identify issues & concerns on a regular basis.
This job description is not all encompassing.

Quality Claims Auditor: This position exists to ensure the integrity of outside medical payments for the organization through verification of the accuracy of data-entered info & by auditing srv related info & invoice adjudication/payment for compliance w/contract terms & Dept/Regl policy & procedures. The auditor must be thoroughly familiar w/outside medical systems & claims processing/adjudication processes. The Auditor must independently perform comprehensive audits of claims to source documents & identify inaccuracies. Conduct quality audits of claims, pre & post payments, utilizing appropriate sources of info, including eligibility, enrollment, provider contracts, policy & procedures. The position requires research, problem resolution & specialized knowledge in the areas of contracts, Medicare & Medi-Cal regulations & reimbursement rules, Multiplan & Beechstreet, Worker's Compensation, Coordination of Benefits & Third Party liability. The auditor must also be capable of developing a working relationship w/regulatory agencies. The level of involvement depends on the specific location. Ensures timely intervention into the srv quality issues in order to enhance srv delivery & customer satisfaction.

 

Essential Functions:
Participate in appropriate & approved training classes during year (in accordance w/goals). Conduct COC training for the WC Auditors. Cross train Oakland Auditors on various NCAL audits. Provide system &/or claim training for internal & external Audit entities (SOX, AON, etc.) As needed, train other teams & Depts.
Data analysis on current reports (error reports, review trend analysis reports for accuracy, etc). Provide analysis on errors identified in the OPA, SOX & AON audits by determining the root cause for each error reported.
In-srvs staff members on new & existing policies & procedures. Active member on the Policy Statement team. Collaborate on new error codes or policy statements. Participate in the training &/or communication of the updates after Core team approval.
Conduct Audit-the Auditor Quality Assurance.
Supervise & distribute the QC tool work w/QA Supv. Prepare & distribute reports to Mgmt, HPRS, NCO,&Internal Audit staff.
Run the unassigned inventory reports from the QC tool weekly & distribute the audits to the Auditors in Oakland & WC. Redistribute work in the QC Tool as needed. Provide CCA Compliance, QA & Operations Mgmt w/outstanding audits, denial, OPA accuracy, overpayment & underpayment reports throughout the month.
Prepare & conduct OJT schedule.
Prepare & present material for CQI meetings.
Broad application of principles, theories, & concepts in applicable discipline, plus working knowledge of other related fields. Implement the Continuum of Care audit process & the trainee new hire audit process. Work w/HP & TPMG auditor to align the co-payment process w/the Continuum of Care audits. Train the auditors & assist the training Dept w/the training material.
This job is the fully-qualified, career-oriented, journey-level position.
Works on problems of diverse scope where analysis of data requires evaluation of identifiable factors.
Awareness of work required at next level & working at that standard.
Provide feedback for the operations team, auditors on the identifiable factors.
Demonstrates good judgment in selecting methods & techniques for obtaining solutions.
Networks w/Sr internal & external personnel in own area of expertise. Network w/systems, training, finance, contracting, operations, compliance & other teams to identify issues & concerns on a regular basis.
This job description is not all encompassing.

Qualifications

Basic Qualifications:
Experience
Minimum three (3) years of claims auditing experience.
Education
Bachelor's degree in related field, OR four (4) years of experience in a directly related field.
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
N/A
 
Additional Requirements:
Articulates well the mission, vision and objectives within two or more major departments of operating units.
Describes functions key responsibilities and practices of multiple departments and units.
Listens actively and demonstrates sensitivity to staff members/customers, encouraging them to discuss concerns, interests, needs and difficult issues.
Consistently monitors own work and seeks further experiences to ensure continual quality patient/customer service delivery.
Puts forward ideas assertively and directly influencing others to identifed issues and concernts.
Adapts ideas well and ties them to the needs and goals of others in order to gain their support and commitment.
Must be able to work in a Labor/Management Partnership environment.
 

Preferred Qualifications:
N/A

Basic Qualifications:
Experience
Minimum three (3) years of claims auditing experience.
Education
Bachelor's degree in related field, OR four (4) years of experience in a directly related field.
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
N/A
 
Additional Requirements:
Articulates well the mission, vision and objectives within two or more major departments of operating units.
Describes functions key responsibilities and practices of multiple departments and units.
Listens actively and demonstrates sensitivity to staff members/customers, encouraging them to discuss concerns, interests, needs and difficult issues.
Consistently monitors own work and seeks further experiences to ensure continual quality patient/customer service delivery.
Puts forward ideas assertively and directly influencing others to identifed issues and concernts.
Adapts ideas well and ties them to the needs and goals of others in order to gain their support and commitment.
Must be able to work in a Labor/Management Partnership environment.
 

Preferred Qualifications:
N/A

About Kaiser Permanente

Company Description

Serving approximately 8.7 million members in nine states and the District of Columbia, Kaiser Permanente is America's leading nonprofit integrated health plan.

Kaiser Permanente's mission is to provide high-quality, affordable health care services to improve the health of our members and the communities we serve.

Our Northern California Region provides integrated health care services to approximately 3.2 million members. Approximately 4,400 physicians of The Permanente Medical Group provide services at 20 medical centers and numerous medical offices.

Company History

Founded in 1945, Kaiser Permanente is the nation’s largest not-for-profit health plan, serving more than 8.6 million members, with headquarters in Oakland, Calif. It comprises:

  1.   • Kaiser Foundation Health Plan, Inc.

  • Kaiser Foundation Hospitals and their subsidiaries

  • The Permanente Medical Groups.

At Kaiser Permanente, physicians are responsible for medical decisions. The Permanente Medical Groups, which provide care for Kaiser Permanente members, continuously develop and refine medical practices to help ensure that care is delivered in the most efficient and effective manner possible.

Kaiser Permanente’s creation resulted from the challenge of providing Americans medical care during the Great Depression and World War II, when most people could not afford to go to a doctor. Among the innovations it has brought to U.S. health care are:

  • prepaid health plans, which spread the cost to make it more affordable

  • physician group practice to maximize their abilities to care for patients

  • a focus on preventing illness as much as on caring for the sick

  • an organized delivery system, putting as many services as possible under one roof

Mission & Values

As a health care organization in the 21st century, we have a mission--to provide quality care for our members and their families, and to contribute to the well-being of our communities.

Working Here

When you bring your career to Kaiser Permanente, the work you do directly affects the health of millions. From the business people who shape our policies, to the IT professionals enabling life-saving data, to the nurses and physicians on the front line of patient care, everyone here has a role to play in the care continuum. Knowing you have a place in that process and witnessing the outcome of the work you do is empowering. It gives you a cause to stand behind. And it makes you feel proud of the work you do every day. When people witness the impact of their contributions, they excel. Together we have the power to make a difference.

Hiring Information

The first step in beginning your career search is to look for open jobs that match your skills, qualifications, and interests. Each posting includes a description of the position and the minimum required qualifications. Once you find a position you are interested in, register for an account and provide your information for consideration online.

Benefits

As an employee, you are eligible for benefits according to your full-time/part-time status and the number of hours scheduled to work per week. Benefits may vary based on your Kaiser Permanente region, position, scheduled hours, and representation by collective bargaining or employee groups, but generally include:

  • generous vacation, holiday, and sick leave

  • medical care (including prescriptions), vision, mental health, and dental care

  • disability and life insurance coverage

  • educational opportunities and tuition reimbursement

  • employee assistance programs

  • health care, dependent care, and transit spending account options

  • retirement plans

In addition, we believe in recognizing stellar performance and sponsor a variety of programs designed to reward our skilled, innovative, caring, and committed staff.

In short, at Kaiser Permanente, we understand that there is a direct correlation between happy employees and happy members. We take pride in the compassion and dedication of our employees and find many ways to reward their hard work. In return, our employees take pride in being a part of a collaborative, professional team focused on quality, service, and care.

Honors & Awards

Kaiser Permanente of Northern California has earned an "Excellent" rating from the National Committee for Quality Assurance (NCQA)-the nation's leading reviewer of health plan quality for consumers and employers. Excellent is the top rating granted by NCQA, which reviews satisfaction surveys, preventive measures, physician credentialing, member services and improvement initiatives.*

Both our Northern and Southern California regions were the only health plans in California identified by the NCQA in its list of the best health care programs in the Pacific States. (NCQA's The State of Health Care Quality 2003)

The Joint Commission on Accreditation of Healthcare Organizations accredits all Kaiser Foundation Hospitals in California.

For the seventh straight year, no other health plan has earned higher ratings from the California Cooperative Health Reporting Initiative on more measures than Kaiser Permanente. The annual ratings measure clinical quality and member satisfaction. (CCHRI Report on Quality 2003)

Our Northern California region received more three-star "Excellent" ratings than any other health plan surveyed by California's Office of the Patient Advocate on California's Quality of Care Report Card 2003-04.

* Commercial HMO and Medicare-contracted product lines: April 2003.