Claims Examiner

RIVERSIDE SAN BERNARDINO COUNTY INDIAN HEALTH INC•Banning, CA

4d•$21 - $21•Onsite

About The Position

Applicant must possess a High School diploma or equivalent, along with experience in healthcare billing and financial management.. A minimum of two years of business-related experience is required, and experience in a healthcare business office is preferred. Experience working in a medical insurance office, social services agency, or other medically related setting will also be considered. Knowledge of healthcare practice privacy rules and regulations, medical terminology, and medical billing principles and practices. Nextgen and Microsoft office software desired. Ability to communicate effectively in writing and orally with a wide variety of health providers and patients regarding PRC policies. Perform routine duties independently, following prescribed regulations, guidelines, and well-established procedures. The Claims Examiner is responsible for determining eligibility for purchase referred care (PRC) Patients and who would be responsible for payment according to tribal affiliation pricing and I.H.S. guidelines. This Claims Examiner is responsible for timely claims payment, pricing and posting of payments. Must be able to work with the Indian community and be sensitive to the Indian culture and its needs.

Requirements

Applicant must possess a High School diploma or equivalent, along with experience in healthcare billing and financial management.
Two years experience in business required; prefer experience in health care business office. Medical insurance office, social services agency or other medically related experience will be considered.
Must have current CPR certification that complies with the guidelines set by the American Heart Association (AHA) or the American Red Cross. Certification may obtained within 90 days of employment.
Medical terminology, understanding of ICD, Revenue & CPT Codes. Current knowledge of healthcare practice privacy rules and regulations, medical terminology, and medical billing principles and practices needed. Familiar with Plexis, Nextgen and Microsoft office software, Indian Health Services guidelines. Knowledge of MLR pricing and how to calculate price depending on the type of service; Inpatient, Outpatient, Anesthesia and Labs, Etc. Familiar with calculating current Wage Index when using MLR.
Communicate effectively in writing and orally with a wide cariety of health providers and patients regarding PRC policies. Perform routine duties independently, following prescribed regulations, guidelines, and well-established procedures. Non-routine assignments are closely supervised by the supervisor. Must be able to work with the Indian Community and its needs. Maintain confidentiality, security and safety of the patient files and provider records at all times. Must possess the ability to be tactful and discreet in the office and community setting as incumbent will be involved in highly confidential matters.

Responsibilities

PROCESSING PRC CLAIMS:
Determine eligibility for PRC and who is responsible for payment, according to Tribal affiliation.
Create a new task in Nextgen, for patients that require screening, proof of address, etc.
Retrieve documentation needed for processing claims through our other clinics, patients, providers, insurance, Medicare and Medi-Cal by phone, mail, fax and/or email.
Work closely with The Referral Management Department for Authorizations and Referrals.
Close the referral when processing the claims.
Input ER and Hospital notifications as received by patient, family member or hospital staff to insure proper payment.
Enter Soboba notifications into the shared Carefinity program.
Process patient statements by contracting the provider of care of acceptable claim form, ie. UB02, HICFA 1500 or an ADA (American Dental Assoc.) along with Primary Insurance Explanation of Benefits if applicable.
Handle Collections notices in the following manner: Call the provider of service because we do not make payment to Collection Agencies, nor do we pay interest or late fees and notify them that it is unlawful to send Native Americans to Collections, as long as we have authorized the service. Provide them with the ‘Patient Protection and Affordable Care Act” letter, signed and put into law by President Obama in 2010.
Maintain a separate tracking system for statements and pending claims.
Request W-9 form from new providers and input all information into system, scan and send a copy to finance.
Enter and maintain all code tables in Plexis as needed for new or missing ICD10, Cause, CPT, Revenue, Denial codes, etc.
Process and maintain denials, including paper denial letters.
Determine eligibility and authorization status daily for tribes with TPA, via email/phone or fax requests.
Track and fax, mail or email (depending on tribe) all claims received, to TPA’s on a weekly basis.
When clearing a claim to finance for payment, posting to the commitment register is required twice. Initial posting requires object class codes, actual payment amount. After the check is complete and mailed, the packet is returned to PRC for final posting to the Commitment register and filing. (Check number, amount paid, check amount and the date paid.)
Process and mail Explanation of Benefits to patients for payment/denial information.
Process and sort mail daily, review all documentation for proper benefit determination, regarding pay and or denial. Reroute incoming calls to proper department.
Separate and document all mail for tribes with a TPA.
Update and maintain spreadsheets for Contracted, Non contracted and LOA providers.
Other duties as assigned