CHS/PRC Claims Specialist

Nisqually Indian Tribe•Olympia, WA

61d

About The Position

The CHS/PRC Claims Specialist works with the Business Office Staff to coordinate specialty referred care, manage benefits, approve services under IHS eligibility guidelines, and provide customer service to the population served. The position supports prompt, accurate financial processing and reporting for financial obligations. It has regular contact with or control over Indian Children and Vulnerable Adults and is subject to the stated federal criminal-background restrictions. The job posting also notes Nisqually’s sex-offender registration requirements. The Specialist administers contracted health care for eligible clients and patients under IHS federal guidelines, program policies and procedures, applicable federal rules and regulations, and available annual funding. The role processes routine and complex health claims, assists patients and providers, issues authorizations, verifies eligibility and alternative insurance resources, generates and tracks purchase orders, matches EOBs, handles invoices and payments, and responds to payment-status inquiries. The position also performs correspondence, filing, and other clerical duties and participates in relevant meetings and seminars. The Specialist follows safety procedures, reports incidents, responds professionally to emergencies, represents the Health & Wellness Center positively, maintains confidentiality and HIPAA compliance, and participates in staff meetings.

Requirements

High school graduation or equivalent.
Three years of experience in a Purchased Referred Care or Contract Health Service program, or an IHS program specific to Tribal Health services.
Three years of experience processing all types of health and dental claims.
Two years of in-depth knowledge of benefits and claims processing.
Two years of successful customer service experience.

Nice To Haves

Experience in a Tribal PRC/CHS program.
Experience in medical billing in ambulatory and hospital settings.
Experience and knowledge of state, federal, and private insurance.
Strong understanding of private, state, and federal health insurance practices as they relate to processing incoming patient claims.
Flexible, self-motivated, independent, detail-oriented, and reliable.
Experience in customer service.
Knowledge of CPT and ICD-10 billing codes.
Knowledge of medical terminology.
Ability to communicate effectively orally and in writing.
Dependable and prompt.

Responsibilities

Ensure Indian Health Contract Health Service requirements are met for eligible clients and patients and assist with daily CHS program operations.
Administer contracted health care according to IHS federal guidelines, program policies and procedures, federal rules and regulations, and annual funding.
Process routine and complex health claims and provide customer service to patients and providers.
Serve as a resource for clients, community members, and Health & Wellness Center staff.
Conduct face-to-face and telephone contact with PRC/CHS-eligible clients and issue authorizations for medical care.
Assist in determining patient eligibility under IHS/PRC guidelines and verify that alternative medical insurance resources are used before PRC services are provided.
Generate purchase order numbers in the current PRC operating system for patients requesting them by telephone or in person.
Match Explanations of Benefits to existing purchase orders.
Verify and document the status of existing purchase orders to complete billing and help ensure timely payments.
Work with off-site specialty providers regarding referrals and services, including physician visits, laboratories, pharmacies, and dental providers, and communicate with patients by mail or in person.
Invoice PRC/CHS claims and post payments daily.
Respond to referring physicians and their billing contacts regarding payment status.
Open and sort incoming correspondence.
Participate in seminars and meetings related to Purchase Referred Care/Contract Health Services.
Perform filing and other common clerical duties.
Follow Health & Wellness program safety policies and procedures.
Report inappropriate incidents by completing incident reports and forwarding them to the immediate supervisor.
Respond calmly and professionally to emergencies and report to the designated area or person.
Represent the Nisqually Tribal Health & Wellness Center positively and professionally when interacting with patients and the community.
Maintain positive interpersonal relations with staff, providers, and management.
Maintain confidentiality and follow HIPAA guidelines.
Participate in staff meetings.