Description: Responsible for initiating the pre-certification requests received both through a telephonic queue line and via faxed requests.
Initiates requests by the following: Initial data entry of pre-certification requests based on a documentation standard template and established policies and procedures for the purpose of clinical review, provides the initial review of benefits and eligibility for services requiring authorization and assigns appropriate ICD-9, HCPCS and CPT -4 codes to all pre-certification requests. Also supports the daily activities of the QRM Regional Review Team.
Responsible for initiating the pre-certification requests received telephonically via the Symposium queue lines and via faxed requests.
Provides the initial data entry of all authorization requests based on a documentation standard template and established policies and procedures for the purpose of clinical review.
Performs data entry and approval of all pre-certification notification only requests (no clinical review), utilizing established criteria and guidelines and documenting according to standard templates requirements.
Reviews all pre-certification requests for initial eligibility and benefits of the member, utilizing established criteria and guidelines.
Assigns appropriate diagnosis and procedure codes following coding guidelines for ICD-9, CPT-4 and HCPCS codes for all pre-certification requests.
Provides assistance to specialists or primary care practitioners and office staff on coding and targeted review questions. Maintains current knowledge of both coding and targeted review to ensure that the right requests are initiated and sent to review and that proper coding is done on all requests so as to meet all regulatory guidelines and audit standards which will result in proper reimbursement.
Forwards authorization requests (live caller or documented record) requiring a clinical review to the appropriate review team/staff.
Provides verbal notification, in accordance to policy and procedure for members and providers with respect to the outcome of their request for services.
Responsible for the support of operational activities for the QRM Regional Review Team.
Manage incoming Right Fax physician requests by sorting, entering into auth system and assigning to correct specialty reviewer.
Remains knowledgeable of contract benefits, eligibility guidelines and current relevant State and Federal regulations that affect managed care and utilization management.
Interacts with physicians and their staff as necessary to gather required information needed for clinical reviews.
Maintains excellent customer service and professionalism with providers and members when executing daily responsibilities.
Maintains department productivity standards and accuracy in data entry.
Maintains effective interaction/communication and working relationships with members of the Medical staff, Complex Case Managers, Regional Review RN's and other QRM staff to facilitate the general review process. Also, works cross functionally with other departments such as the Kaiser Permanente Medical Offices, Customer Services, Claims, Provider Relations, Appeals and Risk Management, in striving to meet organizational goals and objectives.
Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes when appropriate to the Intake Review Supervisor.
Knowledgeable and compliant with regional and QRM department specific personnel policies and procedures.
Participates in annual regional and departmental compliance training.
Demonstrates doing the right thing and doing things the right way is an underlying premise in all work related activities and is able to identify location of copy of Principles of Responsibility.
Develops and maintains an awareness of how to report compliance issues and concerns. Identifies issues of wrong doing and promptly investigates and reports to immediate supervisor or Director of Regional Compliance. Assures an atmosphere and culture for staff to report issues of wrong doing.
Excellent interpersonal and communication skills, including skills with a fast paced ACD telephone queue line.
Demonstrated problem solving skills
Ability to build effective working relationships with physicians and their staff, other QRM staff, members, hospitals, vendors and other Kaiser Permanente departments.
Ability to make quick decisions based on available information, take appropriate action and stick to decisions when challenged.
Excellent planning and time management skills including the ability to handle multiple tasks at any given time.
Ability to handle frequent changes.
Ability to deal with interpersonal conflict with a mature attitude.
Committed to the organization to do what is necessary to have a successful intake review program with the ability to conform to established policies and procedures.
Other duties as assigned.
Minimum two (2) years of experience in a medical setting, with at least one of which should be from a managed health care delivery setting.
Minimum two (2) years data entry experience preferably in a health care setting.
One (1) year of college.
License, Certification, Registration
Certificate of Completion of course in ICD-9 and CPT coding required.
Certificate of Completion of course in Medical Terminology required.
ACD queue line experience preferred.
Clinical background preferred.
Primary Location: Georgia,Atlanta,Regional Office - 9 Piedmont 9 Piedmont Center 34 Scheduled Weekly Hours: 40 Shift:
Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type:
Standard Employee Status: Regular Employee Group/Union Affiliation: UFCW - Local 1996 Job Level:
Entry Level Job Category: QA / UR / Case Management Department: QRM Travel: No
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
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