Claims Operations Coordinator III

This is a remote position but applicants need to reside in Nevada.

Supports data collection/interpretation by reviewing routine and non-routine data in claims databases, using working knowledge of KP systems. Following general instructions to collect medical data, validate medical coverage, and verify details in referral requests and/or authorizations and conduct an in-depth review of audit work, in accordance to policies and procedures. Acts in compliance with KP policies by informally mentoring others on compliance policy and maintaining working knowledge of relevant compliance standards, regulatory policies, laws, or accreditation standards.

Follows general instructions to complete tasks during strategic projects and provides recommendations to improve specific process/system issues according to a variety of project metrics. Supports member identification/support processes by obtaining and providing uncommon information related to claims-payment issues and communicates with cross-team peers to understand resolutions that should be proposed to providers and members.

Essential

Pursues effective peer relationships within and across teams to obtain and share resources and information. Listens to, addresses, and seeks performance feedback; acts as an informal resource for less experienced team members. Actively seeks new relevant knowledge and skills based on strengths and weaknesses; reviews others work to help others learn.

Adapts to change, challenges, and feedback with minimal guidance; demonstrates flexibility in work. Assesses and responds to the needs of others to support completion of work tasks. Follows instructions to complete routine and non-routine work assignments with limited supervision.

Collaborates with others to recommend appropriate solutions for routine and non-routine issues; escalates complex issues; communicates progress and information. Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities within ones team.

Supports the payment of claims as directed by: using judgement when gathering information to ensure that all expenditures are reviewed and paid on time in accordance with appropriate benefits and internal protocols with some support; and communicating with claims adjudicators and vendors to provide claims information (e.g. pay decisions, clinical determinations, referral matching) back to adjudicators on payment approval/denial, under a limited degree of supervision.

Acts in compliance with KP policies by: completing routine and non-routine tasks according to policies and procedures that support compliant work, under minimal guidance; conducting an in-depth review of work, providing feedback, and acting as an informal resource to ensure work is completed according to relevant documentation, policies, and processes related to referrals, authorization processes, utilization review; and utilizing working knowledge of relevant claims processing 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 working knowledge of database technologies to review and flag common and uncommon database issues related to system configurations and testing changes; conducting routine and non-routine data and documentation tasks to ensure the accuracy of claims details in claims databases across various regions; and following 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 to help resolve claims-payment issues or provider disputes; and communicating with cross-team peers 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: gathering data on routine and non-routine billing errors and identifying problems with claims, referrals, or other system processes; and reviewing a variety of project metrics to monitor the success of strategic improvement projects.

Qualifications Knowledge, Skills and Abilities: (Core) Ambiguity/Uncertainty Management Attention to Detail Business Knowledge Communication Critical Thinking Cross-Group Collaboration Decision Making Dependability Diversity, Equity, and Inclusion Support Drives Results Facilitation Skills Health Care Industry Influencing Others Integrity Learning Agility Organizational Savvy Problem Solving Short- and Long-term Learning & Recall Teamwork Topic-Specific Communication Knowledge, Skills and Abilities: (Functional) Claims Applications Computer Literacy Contract Review & Claims Validation Customer Experience Data Entry Health Insurance Products Insurance Insurance Coding Insurance Regulations, Policies, and Procedures

Minimum one (1) year 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 two (2) years of experience working in a corporate or business office environment OR Minimum three (3) years of experience working in a corporate or business office environment.

Scheduled Weekly Hours: 40

Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 08:00 AM Working Hours End: 05:00 PM Job

Full-time Job Type: Standard Employee Status: Regular Worker Location: Remote Employee Group/Union Affiliation: NUE-NV-01|NUE|Non Union Employee Job Level: Individual Contributor Department: Reno 10315 Professional Cir - Mbrshp Acctg-Grp Bllng - 3841

$23.17 - $29.93 / hour Travel: Yes, 15 % of the Time