Description: Job Summary:
Under direct and indirect supervision, receive requests for referral to non-Plan medical services and inpatient admissions, review, triage or authorize requests for eligible Health Plan members according to departmental protocols and procedures; communicate appropriate benefit information to Health Plan members and non-Plan providers; provide current information to NWP and other KP staff concerning contracted providers in the community and the relevant financial arrangement involved. Accurately enter information from referral requests, authorized or denied, into HealthConnect (Tapestry) and the claims system (Diamond), accurately maintain inpatient census reports for alliance facilities.

Essential Responsibilities:

Analyze referral requests, ensuring they meet established departmental protocols. Authorize or triage referrals according to the RRC procedure manual, Provider Contracting agreements and Health Plan Service Agreements. Initiate investigation with NWP on aberrant referral requests. Document activity related to the authorization or denial of requests.
Coordinate patient care with the non-Plan providers. Provide information for scheduling of appointments, request the transfer of medical information, Research, resolve and communicate findings for member eligibility issues.
Approve and validate authorization information for payment by Claims Administration. Obtain authorization or denial of continued care, and communicate information to member/facility/non-Plan provider as appropriate.
Interpret referrals limitations, HP Benefits and communicate this information to members, non-Plan providers, NWP providers, Allied Health and other internal staff as appropriate. Provide billing information to providers, including any vendor/non-Plan provider specific contractual information according to contractual arrangements, NWP protocols and RRC departmental policies and procedures.
Interpret maintain and utilize knowledge of HP benefits, contractual arrangements, NWP protocols and RRC departmental policies and procedures. Prompt recognition of procedural defects or shortcomings in the total referral process; assist with the development of procedures that best utilize the resources of the organization. Participate in committees and task forces as requested.
Obtain records or other information from non-Kaiser providers for evaluation of requests for additional services.
Maintain knowledge of Federal and State laws with regard to confidentiality when working with members, employers, non-Plan providers, community resources and other Kaiser Permanente staff.
Receive information from contracted and noncontracted community facilities related to the admission of Kaiser Permanente members. Review this information to determine if this admission has been directed by a Kaiser Permanente clinician, meets urgent/emergent criteria, determine if the services is authorized, advise the facility of authorization status and member benefits for the services requested.
Receive and review admission and discharge notices from inpatient facilities, comparing this information to previous day reports to update referral records and assure the inpatient census reports are accurate.
Participate on committees or task forces as requested. Basic Qualifications: Experience

Minimum three (3) years of previous work experience with in Kaiser Permanente Claims Administration, Health Plan or Clinical Operations or equivalent experience in related field. This experience must demonstrate the use of coordination of skills, the ability to assimilate technical information and the ability to maintain effectiveness in a busy environment.
Education
High School Diploma or General Education Development (GED) required. License, Certification, Registration N/A Additional Requirements:
Excellent oral and written communications.Ability to problem solve collaboratively with coworkers, providers and administrators.Utilize past work experience and overall Program knowledge to effectively recommend solutions or alternative choices in non-standard situations.Detail oriented, with the ability to handle multiple tasks in a limited time frame.Current, complete knowledge of Health Plan policies, procedures and benefits specifically those benefits that are limited or mandated by financial cap, Federal or State legislation or community standards.Working knowledge of HMO regulations, Medicare regulations and other Federal or State legislation that applies to the provision of medical care.Working knowledge of the computer systems employed by KPNW including HealthConnect, Results Reporting, Common Membership and Diamond.Working knowledge of standard Medical terminology. Preferred Qualifications:
Minimum five (5) years of previous work experience in Kaiser Permanente Claims Administration, Health Plan or Clinical Operations or equivalent experience in related field.. This experience must demonstrate the use of coordination of skills, the ability to work independently with indirect supervision, the ability to assimilate technical information, the ability to maintain effectiveness in a busy environment.Basic knowledge of Provider Relations and Contracting contractual agreements.College degree in health care related field or equivalent combination of knowledge and experience.