Claims Operations Coordinator

Job Summary:

Supports data collection/interpretation by conducting varied tasks to ensure accuracy of data, using advanced knowledge of KP systems. Independently collects medical data, validates medical coverage, and adapts solutions to verify details in referral requests and/or authorizations. Conducts a complex review of audit work and provides feedback. Acts in compliance with KP policies by clarifying compliance policy to team members with less experience and maintaining advanced knowledge of relevant compliance standards, regulatory policies, laws, or accreditation standards. Independently executes tasks during strategic projects, communicating with others across the organization to improve specific process/system issues, and independently reviewing project metrics. Supports member identification/support processes by obtaining and providing information related to complex or unclear claims-payment issues and communicates with cross-team peers and contacts in broader organization to understand resolutions that should be proposed to providers and members.

Essential Responsibilities:

• Pursues effective relationships across teams and/or the organization to obtain and share resources, information, and advice with coworkers and members. Listens to, addresses, and seeks performance feedback; acts as a mentor for less experienced team members. Pursues self-development; creates plans to capitalize on strengths and develop weaknesses; reviews others work to help them learn. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in work; helps others adapt to non-routine situations. Identifies and responds to the needs of others to support the execution of varied work processes.
• Works within established procedures and practices to complete routine work assignments autonomously; follows instructions to complete novel or varied tasks. Collaborates with others to identify and implement appropriate solutions for routine and non-routine issues; escalates high-priority issues or risks; monitors progress and results. Supports the development of work plans to meet established priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities within and across teams.
• Supports the payment of claims as directed by: identifying appropriate solutions or adapts previous solutions to ensure that all expenditures are reviewed and paid on time in accordance with contractual benefits and internal protocols; and independently communicating with claims adjudicators, vendors, and stakeholders (e.g. leadership team) to provide claims information (e.g. pay decisions, clinical determinations, referral matching) back to adjudicators on payment approval/denial and address escalated claims payment issues.
• Acts in compliance with KP policies by: independently executing tasks according to policies and procedures that support compliant work; conducting a complex review of work and provides feedback to ensure work is completed according to relevant documentation, policies, and processes related to referrals, authorization processes, utilization review, clarifying policy to team members with less experience; and utilizing advanced knowledge of relevant claims processing practices and policies to identify relevant compliance standards, regulatory policies, laws, or accreditation standards that should be incorporated into compliance training.
• Supports data collection/interpretation as directed by: utilizing advanced knowledge of database technologies to review and flag unique or complex database issues related to system configurations and testing changes; conducting varied data and documentation tasks to ensure the accuracy of claims details in claims databases across various regions; and independently applying relevant processes and procedures to maintain database workflows.
• Supports member identification/support processes as directed by: obtaining and reviewing uncommon information from cross-team peers, and with some contact with broader organization to help resolve claims-payment issues or provider disputes; and communicating with cross-team peers and contacts in broader organization to understand resolutions that should be proposed to providers and members when addressing claims and benefits inquiries.
• Contributes to improvements to operations and technology processes by: reviewing data on billing errors and identifying problems with claims, referrals, or other system processes; and independently reviewing project metrics to monitor the success of strategic improvement projects.

Minimum Qualifications:

• Minimum two (2) years of experience in referral experience which could be: Referral Services, Claims Membership, Claims Referral Processing, Authorization/Referral Claims Administration or a directly related field.
• High School Diploma or GED, or equivalent AND minimum three (3) years of experience working in a corporate or business office environment OR Minimum four (4) years of experience working in a corporate or business office environment.

Additional Requirements:

• Knowledge, Skills, and Abilities (KSAs): Computer Literacy; Insurance Coding; Compliance Management; Data Entry; Customer Experience; Insurance; Insurance Regulations, Policies, and Procedures; Contract Review & Claims Validation; Health Insurance Products; Claims Applications