Claims Operations Coordinator II

Supports data collection/interpretation by reviewing routine and some non-routine data in claims databases, using basic knowledge of KP systems. Following standard practices for collecting medical data and validating medical coverage, following broad guidance to verify details in referral requests and/or authorizations, and conducting a detailed review of audit work, in accordance to policies and procedures. Acts in compliance with KP policies by ensuring assigned tasks are compliant with policy and maintaining basic knowledge, of relevant compliance standards, regulatory policies, laws, or accreditation standards. Follows standard practices to complete assigned tasks during strategic projects, identifying and voicing problems when specific process/system issues arise, and conducting a detailed review to ensure project metrics are achieved. Supports member identification/support processes by obtaining and providing basic information related to claims-payment issues and communicating with other team members to understand resolutions that should be proposed to providers and members.

• Works with others within work team to obtain and share basic information. Listens and addresses performance feedback; provides feedback to team members. Learns new relevant knowledge and skills; acknowledges strengths and weaknesses based on career goals and takes action to leverage / improve them. Adapts to change, challenges, and feedback with moderate guidance. Responds to the needs of others to support completion of routine work tasks.


• Follows detailed, daily instructions to complete routine tasks with moderate supervision. Collaborates with others within ones team to address routine and some non-routine task issues; communicates status and escalates more complex issues. Adheres to established priorities, deadlines, and expectations. Identifies and speaks up for improvement opportunities within ones team.


• Supports the payment of claims as directed by: conducting some fact-finding to ensure that all expenditures are reviewed and paid on time in accordance with appropriate benefits and internal protocols, under moderate guidance; and communicating with claims adjudicators and vendors to provide claims information (e.g. pay decisions, clinical determinations, referral matching) back to adjudicators on payment approval/denial, under a moderate degree of supervision.


• Acts in compliance with KP policies by: completing routine tasks according to policies and procedures that support compliant work, following detailed instructions, with moderate guidance; conducting a detailed 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 standard 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: using basic knowledge of database technologies to review and correct common database issues related to system configurations and testing changes; conducting routine and some non-routine data and documentation tasks to ensure the accuracy of claims details in claims databases across various regions; and following detailed processes and procedures to maintain database workflows.


• Supports member identification/support processes as directed by: obtaining and reviewing basic information to own team members respond to and resolve claims-payment issues or provider disputes; and communicating with other team members to understand resolutions that should be proposed to providers and members when addressing claims and benefits inquiries.


• Contributes to improvements to operations and technology processes by: identifying problems with claims, referrals, or other system processes with moderate guidance; and conducting a detailed review of project metrics to monitor the success of strategic improvement projects.