Kaiser Permanente Northwest

Compensation

Full Description

Job Summary To support the mission of Kaiser Permanente Northwest (KPNW) through providing the full line of Durable Medical Equipment (DME) products and services to Kaiser Permanente Health Plan members as covered by the DME benefit; including, but not limited to prosthetics, orthotics, DME equipment and supplies, enteral, nutrition and oxygen. Act as a resource for KPNW by providing strong, consistent communication and education of guidelines and procedures to obtain necessary DME. To ensure DME referrals are in compliance with local, state, and federal guidelines, billing instructions and limitations, and benefit eligibility. This position works under the supervision of the DME Manager. Essential Responsibilities • Coordination and procurement of delivery of DME supplies and equipment, including, but not limited to prosthetics, orthotics, DME equipment and supplies, enteral, nutrition and oxygen. • Review, validate and process all eligible physician/clinician referral requests including internal referrals that are faxed, emailed, voicemail, verbally over the phone, or located in EPIC, OneHealthPort. Review referral for appropriateness and completeness, review health record to determine medical need and compliance to all lines of business (LOB) guidelines, work with vendor to coordinate delivery expectations. Communicate referral determination according to DME guidelines based on the line of business (LOB) and/or priority indicated. Maintain compliance to regulatory standards for response times according to Kaiser policy and DME turn-around time (TAT). • Through appropriate utilization review (i.e., based on clinical need, diagnosis, prognosis, and regulatory guidelines) of all equipment determine on-going need of authorized equipment • Ensure customer satisfaction by providing fast, reliable, courteous, auditable, appropriate service to our customers. Act as a liaison for DME services to all customers in the supply chain, both internal and external e.g. Care Coordinators, Discharge Planners, Home Health, Clinicians, Physical Therapy, Respiratory Therapy, Vendors, Claims, Purchasing/Contracting, Pharmacy, Members, etc. to ensure customer satisfaction. Problem-solve, serve as resource, provide information on products, services, and processes. • Research and resolve referral discrepancies initiated by members, vendors, and communications from the claims department. Reconciliation includes differences in quantity, HCPCS codes, and vendor. • Effectively communicate and develop and maintain positive relations interregionally, intradepartmentally and within the business community to ensure professional and ethical business practices. • Provide ongoing communication to management of necessary system maintenance to the DME system to ensure the accuracy of the resource information, including, but not limited to, DME Coordinator Desktop Level Procedures, dot-phrases in EPIC, as well as templates in EPIC. • Strong verbal communication skills in a high call volume call center environment. • Route and escalate calls to appropriate resources and/or management. • Process member manual pay authorization requests per DME guidelines, ensuring that proper receipts are submitted, and timely approvals are sent to claims for member reimbursement. Follow up with claims department on status updates as members inquire on reimbursement. • Perform other duties as assigned by supervisory personnel and DME staff that are consistent with the individuals training and experience. Experience Basic Qualifications: • Minimum one (1) year of experience with PCs/online computer systems. • Minimum two (2) years of experience in a medical environment providing services to patients. • Minimum two (2) years of experience in customer service. Education • High School Diploma or General Education Development (GED) required. License, Certification, Registration • N/A Additional Requirements • Demonstrated experience working independently in a multi-task environment. • Medical terminology. • Basic understanding of Medicare regulations, particularly as they pertain to the provision of Part B benefits. • DME equipment/supply knowledge. • Demonstrates customer-focused service skills. • Excellent communication skills both oral and written. • Keyboard proficient. • Ability to maintain mature problem solving attitude when dealing with interpersonal conflict, difficult people, hostility or time demands. • Commitment to task. • Demonstrated effective decision making and problem solving abilities Preferred Qualifications • Minimum five (5) years of experience in the provision of DME to patients either commercially or in another healthcare organization. • Minimum five (5) years of experience working in direct customer service. • Minimum two (2) years of experience with on-line systems. • Experience working with the elderly. • Knowledge of the Kaiser Permanente systems and processes. • Knowledge of HMO environment. • HCPC coding. • Working knowledge of health plan benefits and policies. • ICD10 coding.