Purchased/Referred Care (PRC) Receptionist (TM46676)

CONFEDERATED TRIBES OF THE COLVILLE RESERVATION•Coulee City, WA

7d•$22 - $27•Onsite

About The Position

SUMMARY: The Claims Processing Specialist is responsible for the accurate and timely processing of claims submitted to the Purchased/Referred Care (PRC) program. This role involves verifying patient eligibility, ensuring compliance with federal PRC regulations, coordinating with providers and vendors, and maintaining detailed records of claims for audit and reporting purposes. The position requires a working knowledge of medical billing codes, insurance reimbursement processes, and the PRC program guidelines governed by the Indian Health Service and tribal policies. This position is distinguished by its specialized knowledge of PRC funding regulations, claims adjudication, and coordination of benefits in the context of Indian Health Service delivery. The role requires a high degree of accuracy, confidentiality, and attention to detail, as well as the ability to work independently and in collaboration with other health service and administrative staff. Familiarity with third-party payers, denial management, and medical coding is essential.

Requirements

High School Diploma or GED required.
Minimum of two (2) years’ experience in medical billing, claims processing, or PRC services.
Working knowledge of PRC program regulations and federal IHS policies.
Proficiency in medical claims processing, including knowledge of CPT, ICD-10, and HCPCS coding systems.
Knowledge of insurance reimbursement systems and coordination of benefits.
Strong analytical and decision-making skills.
Proficient in data entry and electronic health records systems.
Ability to interpret policies, procedures, and medical documents accurately.
Effective written and verbal communication skills.
Ability to maintain confidentiality and comply with HIPAA regulations.
Ability to work under pressure and meet strict deadlines.
Ability to resolve billing discrepancies diplomatically and effectively.
Ability to work independently and collaboratively with clinical and administrative teams.
Ability to prioritize work, multitask, and adapt to changing program requirements.
Ability to explain program eligibility, denials, and payment policies to patients and providers.
Must possess a valid Washington State driver’s license and be insurable under the Tribe’s vehicle insurance policy.
Must pass a criminal background check.

Nice To Haves

Associate’s degree in health administration, business, or a related field preferred.
Experience working with tribal health programs or IHS preferred.
Certification in medical billing or coding preferred (e.g., CPC, CPB, CBCS).
Familiarity with tribal health programs and funding streams is preferred.

Responsibilities

Receives, reviews, and processes PRC claims in accordance with applicable tribal, federal, and IHS PRC regulations.
Verifies patient eligibility and prior authorization status for each claim.
Reviews documentation for completeness, accuracy, and compliance with medical necessity guidelines and program policy.
Determines appropriate payment or denial of claims and documents the rationale for decisions.
Enters claims into the Electronic Health Record (EHR) and/or PRC-specific tracking systems (e.g., RPMS, NextGen).
Ensures timely processing within designated timelines to avoid late payment penalties or audit flags.
Coordinates with external providers and internal staff to resolve billing discrepancies or claim denials.
Prepares Explanation of Benefits (EOBs) and communicates determinations with providers and/or patients.
Supports audits by maintaining detailed and organized claim records.
Participates in training, policy updates, and compliance reviews related to PRC processes.
Assists in reconciliation of PRC financial reports and supports annual reporting requirements.
Ensure confidential handling of sensitive team member information in line with data protection policies
Performs other duties as assigned