Medical Audit Coordinator, RN Specialist

Kaiser Permanente • Oakland, CA

109d

About The Position

The position involves reviewing claims for services obtained outside of Kaiser facilities to ensure compliance with health plan service agreements with members. The role includes identifying health plan claims that may have quality of care issues, continuity of care problems, or access issues at medical facilities. Additionally, the position requires auditing hospital billings on-site at non-plan provider facilities and negotiating successful resolutions of claims. The individual will provide clinical expertise to various departments, including Workers Compensation and outside case management, regarding hospital and physician billing practices and cost containment activities. The role also involves collaboration with the legal department to resolve payment disputes and serving as a consultant to CSA Continuing Care teams and case managers on billing problems and compliance issues. The individual will be responsible for reviewing medical records, coding, and Kaiser Permanente internal systems to determine the payability of bills and identify potential fraud issues. The position requires planning and organizing daily work to meet compliance timeframes and providing feedback to management to ensure adherence to compliance standards. The individual must consistently support compliance and the Principles of Responsibility by maintaining privacy and confidentiality, acting with ethics and integrity, and adhering to applicable laws and regulations.

Requirements

• Minimum five (5) years of clinical experience.
• Graduate of an accredited nursing program required.
• High School Diploma or General Education Development (GED) required.
• Demonstrated ability to work independently and make quick decisions with a high degree of competency.
• Competency in Microsoft Suites (Excel, Access, PowerPoint) and excellent ability with proprietary, mainframe processing systems and KP technologies.
• Strong understanding of medical terminology, ICD-9 coding, and CPT coding principles.
• Ability to work in a Labor/Management Partnership environment.

Nice To Haves

• Minimum five (5) years of clinical experience in critical care preferred.
• Ability to make timely, sound decisions and negotiate successful resolutions in difficult situations preferred.
• Certification or course completion certificates in coding preferred.
• Familiarity with ICD-9 and CPT coding, hospital billing practices preferred.
• Bachelor's degree preferred, or four (4) years of experience in a directly related field.
• Must have RN license in the US and be able to obtain RN license in GA.
• Looking for someone with ICU and UM experience.

Responsibilities

• Review claims for services obtained outside of Kaiser facilities for compliance with health plan service agreements.
• Identify health plan claims with potential quality of care issues, continuity of care problems, or access issues.
• Audit hospital billings on-site at non-plan provider facilities and negotiate successful resolutions of claims.
• Provide clinical expertise to other departments regarding hospital and physician billing practices and cost containment activities.
• Work with the legal department to resolve payment disputes when indicated.
• Serve as a consultant to CSA Continuing Care teams and case managers on billing problems and compliance issues.
• Identify opportunities for cost containment.
• Review ICD-9, CPT codes, medical records, UB-92, and HCFA forms.
• Determine if bills are payable or if additional information is needed, and identify potential fraud issues.
• Plan and organize daily work to meet compliance timeframes.
• Provide feedback to management to ensure work is within compliance standards.

What This Job Offers

• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree