Medical Claims Specialist III - Purchased Referred Care

Alaska Native Tribal Health Consortium•Anchorage, AK

About The Position

Under general supervision, the Medical Claims Specialist III prepares and processes eligible beneficiary referrals and claims for services not directly available at ANTHC, and reviews and adjusts accounts to ensure accurate, thorough claims processing. The role supports Purchased Referred Care (PRC) operations, including claim and referral processing, alternate health resource verification, account review, reporting, and customer support. The specialist also provides leadership and guidance to staff, helps establish goals and assign work, trains and mentors coworkers, and leads projects to improve referral and claims processing efficiency and accuracy. The position works with management to maintain PRC policies and procedures and collaborates with Customer Experience to follow up on and resolve inquiries.

Requirements

Associate’s degree in medical billing and coding, business, finance, accounting, or a related field; progressively responsible accounting technician, medical billing, or related work experience may substitute for education year for year.
Four years of accounting, billing, insurance, medical claims care office, or related experience for the non-supervisory qualification; an associate’s degree in a related field may substitute for two years of experience, or a bachelor’s degree in a related field may substitute for four years. An equivalent combination of relevant education and/or training may be substituted for experience.
Knowledge of electronic medical record systems, ICD-10 and CPT coding, medical insurance processes, alternative health resources, customer service, medical terminology, and clinic systems.
Knowledge of the Privacy Act of 1974 and HIPAA Privacy Rule Act of 1966.
Knowledge of state, federal, and tribal health care programs and state, federal, and public/private insurance, including Medicaid and Medicare.
Ability to work independently and communicate effectively in business correspondence, including grammar, spelling, sentence structure, and business letter writing.
Ability to operate office equipment, including copiers and fax machines, and a personal computer with a variety of software applications.
Ability to interpret state, federal, and public/private insurance financing.
Ability to establish and maintain cooperative working relationships with others.

Responsibilities

Process referrals and medical and transportation claims for beneficiaries authorized to receive services from facilities and providers outside ANMC within established timeframes.
Determine patient eligibility according to established policies and procedures.
Review claims and bills to determine whether a referral is on file or a purchase order is needed; verify diagnosis and treatment codes against referral authorization; determine payable claims and submit purchase orders.
Track and monitor claims, resolve outstanding claims, and research claim status with the Fiscal Intermediary.
Verify insurance carriers and coverage, review claims before submission, assess adjudicated claims, and provide alternate health resource information to providers and facilities.
Identify liability and guarantors; review and adjust account balances; interpret Explanation of Benefits; and analyze billing components on claim forms.
Assist patients, carriers, providers, and other external partners by responding to calls and correspondence and explaining applicable regulations, policies, and procedures.
Research unauthorized claims, referral and claim status, and other customer inquiries in a timely manner.
Verify patient and insurance information and obtain information about Medicaid, Medicare, private insurance, and other liability coverage before authorizing referrals and issuing purchase orders.
Review accounts with credit balances for potential overpayments and participate in payer recoupment, offset, refund request, and voluntary refund processes.
Issue and explain letters of intent or denials under the student and traveler program according to established standards and procedures.
Maintain knowledge of referral and claims processing software, master files, interface conversion tables, and medical-claim tracking data.
Prepare or assist with month-end reports, desk audits, pending-claims reports from the Fiscal Intermediary, and aging purchase-order cleanup.
Prioritize Catastrophic Health Emergency Fund claims for processing and reimbursement; verify records, EOBs, alerts, and purchase orders; and reprice or negotiate claims through Data Isight and Multi-plan Network.
Report workload and process updates, appeals, and patient or provider concerns at weekly staff meetings.
Prepare and maintain case files for review and appeals by the PRC Director or PRC Committee.
Assist with operational reports, purchase-order transmissions, and payment reconciliation.
Work with management to maintain, update, and distribute PRC policies, procedures, guidelines, and standards.
Provide leadership, direction, and guidance to staff; develop goals and priorities with managers and employees; and assign tasks and projects.
Train and mentor staff, lead special projects to improve efficiency and accuracy, assist with workload distribution, support coworkers, and monitor their progress.
Maintain and update PRC specialist desk procedures as processes change.
Collaborate with Customer Experience to ensure timely review, follow-up, and resolution of inquiries; escalate or de-escalate issues according to policy.
Perform other duties as assigned or required.

Benefits

Medical insurance through the Federal Employee Health Benefits Program, with more than 20 plans and tiers.
Cost-share dental and vision insurance.
Discounted pet insurance.
403(b) retirement contributions with pre-tax or Roth options.
401(a) retirement plan with employer matching contributions of up to 5% of eligible pay after one year of employment, based on employee contributions; employees may also be eligible for an annual discretionary employer contribution of up to 3%.
Paid time off beginning immediately, accruing up to six hours per pay period, with accruals increasing based on years of service.
Eleven paid holidays.
Paid parental leave or miscarriage/stillbirth leave eligibility after six months of employment.
Basic short- and long-term disability, AD&D, and life insurance premiums covered by ANTHC; additional voluntary coverage options are available.
Flexible Spending Accounts for healthcare and dependent care.
Ancillary cash benefits for accident, hospital indemnity, and critical illness.
On-site child care facility.
Employee Assistance Program, including grief support, financial counseling, mental and emotional health support, and discounted legal advice.
Tuition discounts for employees and eligible dependents at Alaska Pacific University.
On-site training courses and professional development opportunities.
License and certification reimbursements and occupational insurance for medical staff.
Emergency travel assistance.
Education assistance or education leave eligibility.
Discounts for travel, gym memberships, amusement parks, and more.