 Leader, Coding & Reimbursement - Grade 44This position supports Kaiser Permanente’s code of conduct and compliance by adhering to all laws and regulations, accreditation and Licensure requirements, and internal policies and procedures. Kaiser Permanente is proud to be an equal opportunity/affirmative action employer.
DEPARTMENT: REVENUE CYCLE INTEGRITY
SCHEDULE: Full-time Regular; 40 hours per week; Day Shift; Scheduled day and time are contingent on departmental needs.
POSITION SUMMARY:
The Leader, Coding and Reimbursement is KP’s Northern California recognized content expert in the areas of medical coding, claims reimbursement and medical cost containment for a wide range of customers and clients. These areas include but are not limited to Medical Services Contracting, Senior KP Management, TPMG, Northern California Referrals, North and Southern California Claims, the TPMG Controllers Office, The Inter-regional Risk Adjustment Project, Patient Financial Services and the Regions Outside California. The CRC builds and maintains key relationships with all the above mentioned stakeholders and clients. Provides leadership that results in accurate claims payment with reduced overpayments and errors. The CRC identifies areas in which new approaches or systems will result in additional cost saving. The CRC takes a leadership role to ensure that all Kaiser Regions communicate, share information and are consistent with regard to reimbursement of outside medical providers. Tests and troubleshoots the coding and medical cost containment software that is part of the claims environment for North California . Identifies areas of potential claims savings or loss and takes a leadership roll to inform stakeholders and provide solutions. Promotes a positive and inclusive team environment in which doors are open and problems are addressed in a collegial and supportive manner. Communicates in a manner that is proactive, prompt and persuasive.
EDUCATION/LICENSE/CERTIFICATION: Bachelors degree or equivalent in Business Administration, Health Care Administration, Operations Research, Public Health Administration, or other related field. Strong background and/or certification in medical coding required. Masters degree or clinical licenses (RN, MD, etc.) strongly preferred.
PREFERRED EDUCATION:
Associates Degree/ Bachelors Degree in Healthcare Administration. Either CPC-H or CCS and CPC or CCS-P.
Preferred Education: Must have either Facility & Profee Cert.
QUALIFICATIONS:
· Minimum of five to eight years of progressive experience in healthcare services.
· Extensive knowledge and demonstrated expertise with healthcare delivery systems, with particular emphasis on billing and payment methodologies for medical services and physician and hospital coding practices, including CPT4, ICD9 and UB82 coding applications.
· Medical terminology proficiency and working knowledge of governmental regulations pertaining to HMOs and to Medicare.
· Proven ability to effectively communicate both verbally and in writing with parties who may have different and/or conflicting interests and interpretations. Superior skills in conflict resolution and meeting facilitation. Demonstrated ability to establish working relationships with peers and others, both internal and external to KP.
· Superior leadership and project management skills.
· Expert in all computer systems related to claims processing, as well as internal utilization and benefits. Proficiency with the full suite of Microsoft Office.
· Medical contracting and regulatory agency interface experience preferred.
PREFERRED QUALIFICATIONS:
Medical contracting and regulatory agency interface experience preferred.
SKILLS TESTING: N/A
DUTIES:
- Provides coding and reimbursement consulting services to contracts mangers, analysis staff and provider relations in the Medical Services Contracting Department.
- Member of Provider Dispute Resolution Committee, makes first level appeal determinations for contracted providers.
- Provides and maintains coding and reimbursement expertise based on Medicare and community based payment policies.
- Provides coding and reimbursement support, oversight and clinical review for the referrals payment department and directly reviews all professional invoices paying over $2000.00. Maintains log of the resulting savings.
- Provides feedback to contracts managers on contract adjudication problems and additional opportunities for contract savings.
- Works closely with IT to ensure medical cost containment software is working appropriately and prioritizes installation schedules and software changes. Provides savings reports resulting from using the software and makes suggestions for changing, updating or purchasing new software.
- Distributes an interregional monthly coding and reimbursement newsletter via email to members of the KP claims community and other interested employees.
- As a member of the Inter-regional Risk Adjustment Project, provides analysis and input into diagnosis capture in the claims environment.
- Provides in-services on medical cost containment to claims processors in both claims and referrals environment.
- Provides project management for coding and reimbursement challenges that affect Medical Services Contracting, the Controllers Office and TPMG.
- Provides appropriate placement of medical codes into software systems created to provide cost and utilization analysis.
Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente’s Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente’s policies and procedures.
Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.
- Kaiser Permanente is an AA/EEO employer -
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