Claims Admin Analyst

$51,000 - $65,890/Yr

Kaiser Permanente - Los Angeles, CA

Full-time - Entry Level

Los Angeles, CA

10,001+ employees

Ambulatory Health Care Services

About the position

The Claims Admin Analyst position at Kaiser Permanente is designed to support the Outside Medical Services department by coordinating and processing referrals in compliance with regulatory and organizational guidelines. The role involves communication and problem-solving between medical center physicians, administration, outside providers, and members to ensure efficient processing of medical claims and referrals.

Responsibilities

• Review physicians' requests for outside medical services.
• Verify patient eligibility and communicate with outside facilities and patients regarding billing and appointment scheduling.
• Process billings received from outside medical providers and verify authorized services.
• Determine the accuracy and appropriateness of charges and reroute questionable billings.
• Follow up on referral compliance and maintain files on outside referral patients.
• Educate community hospital personnel and physicians on Kaiser’s referral and reimbursement policies.
• Act as a liaison between regional offices and local outside referral desks.
• Provide accurate information to outside providers and members regarding healthcare routes.
• Interpret and implement procedures regarding contractual agreements with community hospitals and physicians.
• Perform administrative duties as required, including cost avoidance policies and processing referrals.
• Analyze referrals and claims information for accuracy and provide feedback as necessary.
• Assist Claims Auditor with tracing inaccuracies and propose remedial actions.
• Prepare detailed analysis of claims activity and submit reports as requested.
• Monitor and coordinate special transactions such as check adjustments and credits.
• Review and audit medical claims submitted by non-plan providers for accuracy.
• Consult with clinical staff to determine medical necessity of procedures performed by non-plan providers.
• Respond to provider appeals related to disputed claims payment.

Requirements

• Minimum one (1) year of related work experience.
• Bachelor's degree in a healthcare-related field or four (4) years of experience in a directly related field.
• High School Diploma or General Education Development (GED) required.
• Familiarity with medical terminology is required.
• Strong negotiation, conflict resolution, and interpersonal skills are required.
• Proficient with software applications such as Word and Excel.
• Strong analytical skills and excellent oral and written communication skills are required.

Nice-to-haves

• Proficient with EPIC/Health and other software applications.
• Knowledge in Access database is a plus.

Benefits

• Health insurance
• Dental insurance
• Vision insurance
• 401k retirement plan
• Paid holidays
• Paid time off
• Flexible scheduling options