Claims Processing Specialist PRC (CS-50002)
About The Position
The Claims Processing Specialist is responsible for accurate and timely processing of claims submitted to the Purchased/Referred Care (PRC) program. The role verifies patient eligibility, ensures compliance with federal PRC regulations, coordinates with providers and vendors, and maintains detailed claim records for audits and reporting. It requires working knowledge of medical billing codes, insurance reimbursement processes, and PRC guidelines governed by the Indian Health Service and tribal policies. This position requires specialized knowledge of PRC funding regulations, claims adjudication, and coordination of benefits in the Indian Health Service delivery context. The specialist must demonstrate accuracy, confidentiality, and attention to detail, and be able to work independently and with health service and administrative staff. Familiarity with third-party payers, denial management, and medical coding is essential.
Requirements
- High school diploma or GED.
- Minimum of two years of experience in medical billing, claims processing, or PRC services.
- Working knowledge of PRC program regulations and federal Indian Health Service policies.
- Proficiency in medical claims processing, including CPT, ICD-10, and HCPCS coding systems.
- Knowledge of insurance reimbursement systems and coordination of benefits.
- Strong analytical and decision-making skills.
- Proficiency in data entry and electronic health records systems.
- Ability to accurately interpret policies, procedures, and medical documents.
- 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 work independently and collaboratively with clinical and administrative teams.
- Ability to prioritize work, multitask, and adapt to changing program requirements.
- Valid Washington State driver's license and eligibility for coverage under the Tribe's vehicle insurance policy.
- Must pass a criminal background check; applicable background clearances must be maintained throughout employment.
- If the position is safety sensitive, must comply with pre-employment drug testing; reasonable-suspicion and post-accident drug testing may also apply.
Nice To Haves
- Associate's degree in health administration, business, or a related field.
- Experience working with tribal health programs or the Indian Health Service.
- Certification in medical billing or coding, such as CPC, CPB, or CBCS.
- Familiarity with tribal health programs and funding streams.
Responsibilities
- Process claims submitted to the Purchased/Referred Care program accurately and in a timely manner.
- Verify patient eligibility and ensure claims comply with federal PRC regulations and applicable tribal policies.
- Coordinate with providers and vendors.
- Maintain detailed claims records for audit and reporting purposes.
- Support claims adjudication, coordination of benefits, and denial management.
- Explain program eligibility, denials, and payment policies to patients and providers.
- Resolve billing discrepancies diplomatically and effectively.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
