Claims Operations Specialist III

Supports data collection/interpretation by designing and testing system configuration changes, inputting claims details in claims databases, and utilizing a full working knowledge of KP systems. Identifies and escalates missing referral data, not originally obtained during case documentation, verifies details in referral requests and/or authorizations, and plans and schedules the completion and submission of audit reports. Acts in compliance with KP policies by applying and seeking clarification on compliance protocols, answering questions for team members and specific external contacts on relevant compliance standards, regulatory policies, laws, or accreditation standards. Assists with the collection of business requirements, develops project milestones for strategic projects, conducts analysis in response to standard and non-standard claims process/system issues, and monitors performance metrics. Supports member identification/support processes by analyzing and responding to inquiries, and communicating with internal teams (e.g. OCI, benefits, medical service contracting) to develop resolutions that should be proposed to providers and members.

• Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome.


• Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team.


• Supports the payment of claims by: reviewing or adjudicating standard and non-standard claims to ensure that all expenditures are properly adjudicated and paid on time in accordance with contractual benefits; and communicating with claims adjudicators, vendors, and stakeholders to provide claims information (e.g. pay decisions, clinical determinations, referral matching) back to adjudicators on payment approval/denial, under minimal guidance.


• Acts in compliance with KP policies by: applying and seeking clarification on policies and procedures which support compliance protocols; answering questions for others in the broader organization and contracted providers on relevant documentation, policies, and processes related to referrals, authorization processes, utilization review; and using comprehensive foundational 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 by: helping others identify and design required system configuration changes, and testing system configuration changes to ensure they are error-free; inputting claims details and updating data in the claims database across various regions; and independently creating and maintaining databases and using automated tools which improve workflow.


• Supports member identification/support processes as directed by: analyzing and responding to inquiries regarding claims-payment issues or provider disputes; and communicating with internal teams (OCI, benefits, medical service contracting) to develop resolutions that should be proposed to providers and members when addressing claims and benefits inquiries.


• Contributes to improvements to operations and technology processes by: assisting with the collection of business requirements and developing project milestones for strategic projects designed to remediate issues for impacted groups and improve claims and referral operating efficiency; conducting analysis on claims, referral, or other system processes in response to standard and non-standard claims errors to identify root cause of escalations and process issues; and implementing and monitoring performance metrics to track the success of strategic improvement projects.


• Maintains the intake and management of referral requests by: interpreting broad guidelines to collect inpatient medical data (e.g., charts, records) from internal staff or clinicians, outside providers, and members to determine coverage/benefits and make a referral; identifying and escalating missing patient data not originally obtained during case documentation (e.g., admission, discharge, electronic medical record, demographic) in the referral system so that providers can ensure coordination of care; and independently planning and scheduling the completion and submission of audit reports to ensure referrals have been processed according to quality standards.