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Kaiser Permanente Careers

Quality Assurance, UR & Case Management

Passion + Vision + Integrity = Excellence

Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.

Appeals Specialist

Location: Renton, WA Job Number: 723929 Date posted: 08/08/2018
Description: Triage and document requests for member appeals, OIC complaints, received via phone, fax, email and mail. Research for cases may involve: medical coverage, claims, authorizations, clinical review, eligibility, and interpretation of legal documents. Provide guidance about appeal process and requirements to members, prospective members, providers, other insurance carriers, agents, brokers, attorneys, employer groups and other member representatives over the telephone or via secure email. Answer high volume of complex verbal communication with members and providers interpreting needs in order to assure a clear and accurate assessment of their issue and assist them in a culturally appropriate manner. Prepare all material for case review in a way that meets regulatory requirements and the needs of the Appeal Coordinator who will investigate and/or consult on the case. Provide ongoing support to Appeal Coordinator.


Essential Responsibilities:
  • Setup and prepare electronic case for review by researching claims, authorizations, member contracts, and customer service interactions as well as calling provider office staff to obtain records and billing information. Complex document handling that includes scanning, converting between document types, adobe, redacting, extracting, compressing, secure emailing, secure file transfers, secure faxing. Manage cases without medical issues.
  • Communicate highly sensitive and confidential information (electronic, telephonic, and written), both into and out of Member Appeal. Responsible for managing all incoming and most outgoing requests, ensuring compliance with timelines and HIPPAA confidentiality requirements
  • Composes significant amounts of correspondence from templates. Includes confidential information. Proofreads documents for typographical, spelling and content errors. Provide support for the Appeal Coordinators working cases.


  • Basic Qualifications:
    Experience
  • Minimum three (3) years experience with customers on the phone.
  • Minimum two (2) years of experience working in a medical setting.
    Education
  • Must have some college level courses in a Communications or Health Care field OR two (2) years of experience in health plan customer service.
    License, Certification, Registration
  • N/A


    Additional Requirements:
  • Document handling and data entry.
  • Keyboarding skills while on phone.
  • Microsoft Office products: Word & Excel and Adobe.
  • Organization and prioritizing skills.
  • Attention to detail.
  • Customer service and communication skills on the phone.
  • Can de-escalate difficult calls.
  • Able to clearly translate to documentation what caller is requesting.
  • Able to clearly respond in a culturally appropriate manner.


    Preferred Qualifications:
  • Three (3) years of customer service experience at Kaiser Foundation Health Plan of Washington.
  • Three (3) years of experience working in a medical setting related to billing and/or insurance.
  • Proficiency with software used by the department.
  • Knowledge of IBM Premier system; Lotus Notes; Internet and Intranet research.
  • Organization and prioritizing skills.
  • Attention to detail.

  • Completion of a vocational school/certificate program in a health care related field to include education in medical terminology, coding and HIPPA.

    Primary Location: Washington,Renton,Renton Administration - Rainier 2715 Naches Ave. Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Non-Union, Non-Exempt Job Level: Individual Contributor Job Category: QA / UR / Case Management Department: Appeals Department Travel: No
    Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
  • About QA, Ur & Case Management Careers

    Careers In QA, Ur & Case Management

    As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.

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