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Experience:
No experience
Employment Type:
Intern/Co-op
Posted:
9/9/2015
Job Category:
Health Care Provider
Industry:
Health Care & Medicine
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Regional Referral Center Coordinator
Kaiser Permanente | Portland, Oregon
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Job Description

Under direct and indirect supervision, receive requests for referral to non-Plan medical services and inpatient admissions, review, triage or authorize requests for eligible Health Plan members according to departmental protocols and procedures; communicate appropriate benefit information to Health Plan members and non-Plan providers; provide current information to NWP and other KP staff concerning contracted providers in the community and the relevant financial arrangement involved. Accurately enter information from referral requests, authorized or denied, into HealthConnect (Tapestry) and the claims system (Diamond), accurately maintain inpatient census reports for alliance facilities.

 

Essential Functions:
Analyze referral requests, ensuring they meet established departmental protocols. Authorize or triage referrals according to the RRC procedure manual, Provider Contracting agreements and Health Plan Service Agreements. Initiate investigation with NWP on aberrant referral requests. Document activity related to the authorization or denial of requests.
Coordinate patient care with the non-Plan providers. Provide information for scheduling of appointments, request the transfer of medical information, Research, resolve and communicate findings for member eligibility issues.
Approve and validate authorization information for payment by Claims Administration. Obtain authorization or denial of continued care, and communicate information to member/facility/non-Plan provider as appropriate.
Interpret referrals limitations, HP Benefits and communicate this information to members, non-Plan providers, NWP providers, Allied Health and other internal staff as appropriate. Provide billing information to providers, including any vendor/non-Plan provider specific contractual information according to contractual arrangements, NWP protocols and RRC departmental policies and procedures.
Interpret maintain and utilize knowledge of HP benefits, contractual arrangements, NWP protocols and RRC departmental policies and procedures. Prompt recognition of procedural defects or shortcomings in the total referral process; assist with the development of procedures that best utilize the resources of the organization. Participate in committees and task forces as requested.
Obtain records or other information from non-Kaiser providers for evaluation of requests for additional services.
Maintain knowledge of Federal and State laws with regard to confidentiality when working with members, employers, non-Plan providers, community resources and other Kaiser Permanente staff.
Receive information from contracted and noncontracted community facilities related to the admission of Kaiser Permanente members. Review this information to determine if this admission has been directed by a Kaiser Permanente clinician, meets urgent/emergent criteria, determine if the services is authorized, advise the facility of authorization status and member benefits for the services requested.
Receive and review admission and discharge notices from inpatient facilities, comparing this information to previous day reports to update referral records and assure the inpatient census reports are accurate.
Participate on committees or task forces as requested.

Under direct and indirect supervision, receive requests for referral to non-Plan medical services and inpatient admissions, review, triage or authorize requests for eligible Health Plan members according to departmental protocols and procedures; communicate appropriate benefit information to Health Plan members and non-Plan providers; provide current information to NWP and other KP staff concerning contracted providers in the community and the relevant financial arrangement involved. Accurately enter information from referral requests, authorized or denied, into HealthConnect (Tapestry) and the claims system (Diamond), accurately maintain inpatient census reports for alliance facilities.

 

Essential Functions:
Analyze referral requests, ensuring they meet established departmental protocols. Authorize or triage referrals according to the RRC procedure manual, Provider Contracting agreements and Health Plan Service Agreements. Initiate investigation with NWP on aberrant referral requests. Document activity related to the authorization or denial of requests.
Coordinate patient care with the non-Plan providers. Provide information for scheduling of appointments, request the transfer of medical information, Research, resolve and communicate findings for member eligibility issues.
Approve and validate authorization information for payment by Claims Administration. Obtain authorization or denial of continued care, and communicate information to member/facility/non-Plan provider as appropriate.
Interpret referrals limitations, HP Benefits and communicate this information to members, non-Plan providers, NWP providers, Allied Health and other internal staff as appropriate. Provide billing information to providers, including any vendor/non-Plan provider specific contractual information according to contractual arrangements, NWP protocols and RRC departmental policies and procedures.
Interpret maintain and utilize knowledge of HP benefits, contractual arrangements, NWP protocols and RRC departmental policies and procedures. Prompt recognition of procedural defects or shortcomings in the total referral process; assist with the development of procedures that best utilize the resources of the organization. Participate in committees and task forces as requested.
Obtain records or other information from non-Kaiser providers for evaluation of requests for additional services.
Maintain knowledge of Federal and State laws with regard to confidentiality when working with members, employers, non-Plan providers, community resources and other Kaiser Permanente staff.
Receive information from contracted and noncontracted community facilities related to the admission of Kaiser Permanente members. Review this information to determine if this admission has been directed by a Kaiser Permanente clinician, meets urgent/emergent criteria, determine if the services is authorized, advise the facility of authorization status and member benefits for the services requested.
Receive and review admission and discharge notices from inpatient facilities, comparing this information to previous day reports to update referral records and assure the inpatient census reports are accurate.
Participate on committees or task forces as requested.

Qualifications

Basic Qualifications:
Experience
Minimum three (3) years of previous work experience win Kaiser Permanente Claims Administration, Health Plan or Clinical Operations or equivalent experience in related field. This experience must demonstrate the use of coordination of skills, the ability to assimilate technical information and the ability to maintain effectiveness in a busy environment

Education
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
N/A
 
Additional Requirements:
Excellent oral and written communications.
Ability to problem solve collaboratively with coworkers, providers and administrators.
Utilize past work experience and overall Program knowledge to effectively recommend solutions or alternative choices in nonstandard situations.
Detail oriented, with the ability to handle multiple tasks in a limited time frame.
Current, complete knowledge of Health Plan policies, procedures and benefits specifically those benefits that are limited or mandated by financial cap, Federal or State legislation or community standards.
Working knowledge of HMO regulations, Medicare regulations and other Federal or State legislation that applies to the provision of medical care.
Working knowledge of the computer systems employed by KPNW including HealthConnect, Results Reporting, Common Membership and Diamond.
Working knowledge of standard Medical terminology.

 

Preferred Qualifications:

Minimum five (5) years of previous work experience in Kaiser Permanente Claims Administration, Health Plan or Clinical Operations or equivalent experience in related field.. This experience must demonstrate the use of coordination of skills, the ability to work

independently with indirect supervision, the ability to assimilate technical information, the ability to maintain effectiveness in a busy environment.

College degree in health care related field or equivalent combination of knowledge and experience.

Basic knowledge of Provider Relations and Contracting contractual agreements.

Basic Qualifications:
Experience
Minimum three (3) years of previous work experience win Kaiser Permanente Claims Administration, Health Plan or Clinical Operations or equivalent experience in related field. This experience must demonstrate the use of coordination of skills, the ability to assimilate technical information and the ability to maintain effectiveness in a busy environment

Education
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
N/A
 
Additional Requirements:
Excellent oral and written communications.
Ability to problem solve collaboratively with coworkers, providers and administrators.
Utilize past work experience and overall Program knowledge to effectively recommend solutions or alternative choices in nonstandard situations.
Detail oriented, with the ability to handle multiple tasks in a limited time frame.
Current, complete knowledge of Health Plan policies, procedures and benefits specifically those benefits that are limited or mandated by financial cap, Federal or State legislation or community standards.
Working knowledge of HMO regulations, Medicare regulations and other Federal or State legislation that applies to the provision of medical care.
Working knowledge of the computer systems employed by KPNW including HealthConnect, Results Reporting, Common Membership and Diamond.
Working knowledge of standard Medical terminology.

 

Preferred Qualifications:

Minimum five (5) years of previous work experience in Kaiser Permanente Claims Administration, Health Plan or Clinical Operations or equivalent experience in related field.. This experience must demonstrate the use of coordination of skills, the ability to work

independently with indirect supervision, the ability to assimilate technical information, the ability to maintain effectiveness in a busy environment.

College degree in health care related field or equivalent combination of knowledge and experience.

Basic knowledge of Provider Relations and Contracting contractual agreements.

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.