Kaiser Permanente

Medical Audit Coordinator

Oakland, CA

The Medical Audit Coordinator reviews claims for services obtained outside of Kaiser facilities for compliance with health plan service agreement with members; identifies health plan claims with potential quality of care issues, continuity of care problems, or access issues at medical facilities; and audits hospital billings on site at non Plan provider facilities and negotiates successful resolution of claim.

Essential Functions

• Provides clinical expertise to other departments such as Workers Comp., TPMG referrals, CSA/ MSA outside case management in areas related to hospital and physician billing practices and cost containment activities.


• Works with legal department when indicated to resolve payment disputes.


• The Medical Audit Coordinator serves as a consultant to CSA Continuing Care teams and case managers on issues of non-Plan pricing, billing problems, procedures and benefit compliance issues. Identifies opportunities for cost containment. Works with regulatory compliance for review of benefit.


• Responsible for review of ICD-9, CPT codes, medical records, UB- 92 and HCFA forms as well as Kaiser Permanente internal systems (OTRS, Advice call logs). Determines if bills are payable or if additional information is needed.


• Works with PRS staff as a resource for decision-making and medical terminology.


• Plans, organizes daily work to meet compliance timeframes. Provides feedback to manager to ensure work is within compliance.


• Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization.


• Decisions are made following State and Federal regulations related to provider reimbursement for claims, NCQA standards, Kaiser internal policies related to payment of out of Plan services.


• Determines whether to pay claim or refer to an advisor based on clinical criteria related to emergency medical condition.


• Payable claims are analyzed for correct contract interpretation, Medicare fee schedule interpretation, correct coding.


• Analyzes information from multiple internal and external sources when reviewing a claim episode of care.


• Assigns work based on regulatory compliance, staffing, staff skill level and competing priorities


• The Medical Audit Coordinator serves as a consultant to CSA Continuing Care teams and case managers on issues of non-Plan pricing, billing problems, procedures and benefit compliance issues.


• Works with interregional counterparts for matters of billing resolutions and clinical issues and with regulatory department regarding issues of compliance and interdepartmental review of benefit issues


• Independently prioritizes work on hand based on compliance.


• Expected that this position possess the ability to work with minimal direction from supervisor.


• Has the authority to direct the work of others such as Project Analyst, to meet compliance dates.

Basic Qualifications

•  Graduate of an accredited Nursing Program.


• Current California RN license is required.


• Minimum of 5 years clinical experience, preferably in critical care


• Ability to make timely and sound decisions, and act independently and negotiate successful resolution in difficult situations.


• Proficient in the use of MS Applications (Excel, Access, Power Point), excellent ability with proprietary, mainframe processing systems and KP Technologies


• Demonstrates understanding of medical terminology, ICD-9 coding, CPT coding principles


• Knowledge of LMP required.


• Strong customer service skills


• Must understand DHS, Medicare, ERISA guidelines for payment of claims


• Knowledge of state regulations pertaining to member and provider appeals rights required

Preferred Qualifications

• Bachelor's degree preferred for this position, or the equivalent