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Job Summary:

Under direct supervision, maintains current records of all physician outside referrals of Kaiser Permanente Health Plan members, verifies that outside referrals have proper authorizations for prescribed services, monitors expenditures to determine appropriateness of payment per established guidelines, and sets up reporting systems for the processing of forms required for outside referrals and the payment of outside services rendered.

Essential Responsibilities:

Reviews physicians requests for outside medical services. Verifies patient eligibility and contacts both outside facility and patient regarding billing procedures and appointment scheduling. Reviews and processes billings received from outside medical providers. Verifies authorized services prescribed, determines accuracy and appropriateness of charges. Determines whether questionable billings received are to be considered for payment through the outside medical referral system and reroutes billings. Follows up on outstanding accounts. Sets up and maintains files on all outside referral patients. Sets up files on all no-bed patients and pre-scheduled surgeries, notifies patients and outside providers and processes invoices. Educates community hospital personnel, physicians and billing services regarding Kaiser Outside Medical referral and reimbursement policies and practices, covered benefits and authorized services. Interpret SCPMG, KFH and KFHP policies and answer inquiries from Kaiser members, physicians and other involved personnel and support staff. Act as liaison between Regional Offices and local Outside Referral desk to coordinate and implement all Outside Medical Systems for SCPMG associated with use of non-Kaiser facilities for the purposes of: in and out patient referrals, supplemental bed and pre-scheduled surgeries. Provide accurate information to outside providers and members to help facilitate most appropriate route of health care. Interpret and implement necessary procedures regarding contractual agreements between Kaiser Permanente and Community Hospitals and physicians. Performs other administrative duties as required.

CLAUSE - APPLICABLE TO KERN COUNTY

(BAKERSFIELD)

POSITIONS ONLY

In Kern County Only , this position may only be filled by a candidate to be stationed at 5055 California Avenue. Please use represented Job Code 18800 when posting this position for any other Bakersfield location. Should you have questions please contact your local HR, Labor Representative, or Regional Compensation Consultant.

Qualifications:

Basic Qualifications:

Experience Minimum one (1) year of related work experience requirements. Minimum one (1) year in medical billing, claims, and referrals Minimum one (1) year Experience required CPT and

ICD 9/10

coding knowledge Minimum one (1) year Familiar with coverages and benefits Minimum one (1) year Medical terminology and knowledge of Medicare Guidelines Education High School diploma or General Education Development (GED) required.

License, Certification, Registration N/A Additional Requirements:

Plus knowledge and experience with various computer programs. Good communication and interpersonal skills as well as mathematical skills. Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications:

One year working with Referrals, medical billing, and claims

Notes:

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Coord Outside Referral UHW