Description

Job Summary:

Administer the provision of Durable Medical Equipment (DME), home oxygen and respiratory services, and prosthetic and orthotic devices for eligible Health Plan Members. Coordinate, approve and pay for services. Review orders for compliance and renewal. Assure adherence to billing instructions, billing limitations and other guidelines established by Kaiser Foundation Health Plan of Washington and Medicare. Negotiate prices with DME providers and vendors on an ad hoc basis with specific case.

Essential Responsibilities:

• Review, verify need, and authorize or deny patient care staff initiated DME referrals. Communicate and collaborate with referring provider regarding appropriateness and completeness of request. Identify special or unusual orders for high cost equipment. Assist HLNs with utilization management decision and describe cost saving alternatives. Approve and coordinate equipment requests by review of patient records and/or discussion with HLNs, Respiratory Therapists, or medical advisor as appropriated. Negotiate case-specific prices with DME vendors when appropriate. Coordinate appropriate equipment delivery or pickup with contracted vendors, via FAX or telephone. Determine urgency of delivery based on medical need. Enter and process selected patient medical information into RMS to produce vendor authorization, provide computer generated statistical data regarding KFHPW DME liabilities, and to allow reimbursement for services.
• Communicate and negotiate acceptable resolutions to conflicts with Health Plan members, WPMG providers, patent care staff, and vendors. Problems solve complex consumer issues regarding patient care. Review and determine the continued need for equipment based on cost effectiveness, duration of use, diagnosis, and prognosis of patient via physician or other patient care staff. Determine continuation of rental versus purchase of equipment based on the medical needs of the patient, and cost effectiveness. Maintain automated system to identify expiration of referrals for DME. Coordinate care prior to expiration date of referral.
• Determine member eligibility for DME services. Provide detailed information to enable clarification of benefit limitations, and interpretation of Service Agreements. Recommend cases for consideration of benefit exceptions for DME. Interpret and maintain knowledge of current Medicare guidelines and other regulatory requirements. Interface regularly with Medicare experts to stay current on Medicare benefits. Research with Medicare and the community for evolving standards with regard to the provision of DME, recommending appropriate course of action. Develop and maintain relationships with Provider Relations Medical Supplies Services Manager.
• Analyze and process DME claims for reimbursement received from members, various KFHPW departments, or other sources. Investigate the reasons for these claims; determine appropriate reimbursement or finial for services/equipment. Scrutinize invoice charges against vendor price lists, and Medicare allowable guidelines. Authorize appropriate reimbursement. Identify patient requested service upgrades and manage them appropriately. Act as a liaison with DME vendors to help negotiate services for patients without DME coverage.
• Educate members, an implement in -service orientations for KFHPW providers, and other patient care staff as to current DME processes, including the completion of the Certificate of Medical Necessity (CMN). Identify areas in need of process improvement and initiate improvement. Develop the process and manage the administration of the CMN.

Basic Qualifications:

Experience

• Minimum five (5) years of health care experience including referral processing and working with the public, with emphasis on problem solving and conflict resolution.
• Minimum two (2) years of experience using on-line computer systems.

Education

• Associates degree OR two (2) years of experience in a directly related field.
• High School Diploma OR General Education Development (GED) required.

License, Certification, Registration

• N/A

Additional Requirements:

• Computer skills in Windows environment including MS Word and Excel; and Kaiser Foundation Health Plan of WA applications.
• Communication and interpersonal skills.
• Working knowledge of Health Plan benefits and policies and medical terminology.
• Basic understanding of Medicare regulations, particularly those pertaining to the provision of Part B services.

Preferred Qualifications:

• Three (3) years of progressive experience in a health care setting or related field.
• Kaiser Foundation Health Plan of WA work experience.
• Experience with DME vendors.
• Referrals and claims experience.
• Bachelors degree in health care related field.

Primary Location: Washington,Renton,Renton Administration - Rainier
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Sun, Mon, Tue, Wed, Thu, Fri, Sat
Working Hours Start: 08:00 AM
Working Hours End: 05:00 PM
Job Schedule: Full-time
Job Type: Standard Worker Location: Flexible
Employee Status: Regular
Employee Group/Union Affiliation: J04|OPEIU|OPEIU Local 8
Job Level: Individual Contributor
Department: Renton Admin Rainier - Grp Reltn-Review Svcs Mgt/Supp - 1130
Pay Range: $32.12 - $44.54 / hour Travel: No Flexible: Work location is on-site at a KP location, with the flexibility to work from home. Worker location must align with Kaiser Permanente's Authorized States policy. Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.
Requisition #: 1388522

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