To support the mission of the Northwest Region through the commitment of organization funds in administering the DME Benefit. This includes providing the full-line of products and services to Kaiser Permanente Health Plan members as covered by the Durable Medical Equipment (DME) benefit to include: prosthetics, orthotics, DME equipment and supplies, enternals/nutritionals and oxygen. To act as a resource for physicians, clinicians and health plan members throughout the region. To ensure orders are in compliance with Kaiser Permanente, OMAP and Medicare guidelines, billing instructions and limitations, and benefit eligibility. This position works under indirect supervision of the DME Manager in Materials Management.
Procurement of DME supplies and equipment. Negotiate and procure supplies and services through established Purchasing standards, contracts and sources. Review, validate and process all eligible physician/clinician referral requests; review referral for appropriateness and completeness, review health record to determine medical need and compliance to Medicare guidelines, contact vendor, coordinate delivery and pick-up of equipment with vendor/clinician/patient. Maintain compliance to regulatory standards for response times. Insure member eligibility for DME services: both benefit and current Medicare guidelines.
Manage costs through effective utilization review of rental equipment. Determine on-going need of rental equipment/supplies/oxygen based on clinical need, diagnosis and prognosis, regulatory guidelines. Work with appropriate clinician/physician to proactively recommend cost-effective changes in service delivery e.g. rental to purchase, discontinuation of service, step-down or product category, etc.
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 invoice and claims discrepancies. Reconcile differences in quantity, description, or pricing of equipment/products and services. Analyze and process DME claims for reimbursement received from members, various KP departments and other sources. Investigate reasons for these claims, determine appropriate reimbursement, and authorize payment.
Effectively communicate and develop and maintain positive relations interregionally, intradepartmentally, and within the business community to insure professional and ethical business practices.
Provide ongoing system maintenance to the DME system to ensure the accuracy of the information. Research and discontinue recurring POPAs as appropriate. Identify and remove outstanding liabilities as appropriate. Ensure all POPAs have accurate HCPC codes and modifiers identified in the system. Perform other duties as requested.
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.
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
Demonstrated experience working independently in a multi-task environment.
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.
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
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.
Working knowledge of health plan benefits and policies.
TITLE: DME Benefit Coordinator II
LOCATION: Portland, Oregon
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, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
- Claim Processing
- Clinical Works
- Computer Keyboards
- Contract Management