Referral Specialist - Must be within an hour of Portland

Supports data collection/interpretation by interpreting system configuration changes, inputting claims detail in claims databases, and developing a basic knowledge of KP systems. Enters, or updates standard referral data, sorts and maintaining referral requests and/or authorizations and assists with the completion of simple audit reports. Acts in compliance with KP policies by adhering to compliance protocols, obtaining basic information for team members on relevant compliance standards, regulatory policies, laws, or accreditation standards. Completes tasks as requested to support strategic projects, supporting analysis on claims, and maintain performance data. Supports member identification/support processes as directed by collecting information for others and communicating with lead to understand resolutions that should be proposed to providers.

• Pursues effective relationships with others by sharing information with coworkers and members. Listens to and addresses performance feedback. Pursues self-development; acknowledges strengths and weaknesses, and takes action. Adapts to and learns from change, challenges, and feedback. Responds to the needs of others to support a business outcome.
• Completes routine work assignments by following procedures and policies and using data, and resources with oversight and management. Collaborates with others to address business problems; escalates issues or risks as appropriate; communicates progress and information. Adheres to established priorities, deadlines, and expectations. Identifies and speaks up for improvement opportunities.
• Supports the payment of claims as directed by: learning to review claims to ensure that all expenditures are properly adjudicated and paid on time in accordance with contractual benefits under close guidance; and communicating with claims adjudicators and immediate manager to provide claims information (e.g. pay decisions, clinical determinations, referral matching) back to adjudicators on payment approval/denial, under close guidance.
• Acts in compliance with KP policies by: adhering to policies and procedures which support compliance protocols; conducting a moderately complex review of work and providing feedback to ensure work is completed according to relevant documentation, policies, and processes related to referrals, authorization processes, utilization review; and utilizing basic knowledge of 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: interpreting system configuration changes under close guidance; inputting claims detail in claims databases across various regions, following close instruction; and following detailed instructions to maintain databases and use automated tools which improve workflow.
• Supports member identification/support processes as directed by: collecting information on to equip others to respond to inquiries regarding claims-payment issues or provider disputes; and communicating with lead to understand resolutions that should be proposed to providers and members when addressing claims and benefits inquiries.
• Supports improvements to operations and technology processes by: completing tasks as requested to support strategic projects designed to remediate issues for impacted groups and improve claims and referral operating efficiency; working with others to conduct analysis on claims, referral, or other system processes under close guidance of others; and supporting the maintenance of performance data related to strategic improvement projects, as requested.
• Supports the intake and management of referral requests by: following detailed protocols to collect inpatient medical data (e.g., charts, records) from internal staff or clinicians, outside providers, and members used by others to determine coverage/benefits and make a referral; capturing, entering, or updating standard patient data information (e.g., admission, discharge, electronic medical record, demographic) in the referral system so that providers can ensure coordination of care; and assisting with the completion and submission of simple audit reports within appropriate time frames under close guidance from others to ensure referrals have been processed according to quality standards.