Lead Research and Resolution Adjustor - MUST RESIDE IN COLORADO

Kaiser Permanente; Denver (CO); On-site; USD 70,000 - 100,000; Full time

Job summary

Kaiser Permanente in Denver seeks a seasoned Research & Resolution Claims Specialist to provide technical assistance to Claims Adjustors, participate in audits, and train staff. You will focus on member needs, resolve complex inquiries, and support improvements in claims processes.

Responsibilities include verifying inquiries per policies, researching claims, documenting determinations, and contributing to training programs.

Qualifications

• 5+ years of medical claims adjudication in an integrated health plan environment.
• At least 2 years processing high complexity adjustments and high-dollar claims.
• Basic PC skills and proficiency with standard office software.
• Working knowledge of Microsoft Word.
• 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.
• Demonstrated complex problem solving and decision making.
• AA degree, accounting or business related (preferred).

Responsibilities

• Verify the intent of the inquiry and ensure adherence to contractual agreements and pricing as well as government regulations.
• Locate necessary information relevant to the claim and communicate with stakeholders.
• Research services rendered to determine correct processing and denial accuracy; review and address adjustments.
• Document clear case summaries and take next steps to resolve inquiries.
• Provide input on training opportunities and assist with staff education; participate in meetings as requested.

Skills

Customer service

Communication

Problem solving

Education

High School Diploma or GED

Tools

Microsoft Word

Microsoft Excel

Job description

• -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.