Purchased Referred Care (PRC) Claims Technici

Great Plains Tribal Leaders Health Board Inc•Rapid City, SD

About The Position

Primary responsibilities involve repricing outside vendor claims according to federal guidelines and OHC PRC policies. This position uses the functions within RPMS, EHR and repricing software to analyze vendor claims and reprice them to Medicare-Like Rates.

Requirements

Exemplify excellent customer service with tribal stakeholders, health board colleagues, program partners, service recipients, visitors, and guests.
Foster a work environment of wellness, courtesy, friendliness, helpfulness, and respect.
Relate well and work collaboratively with coworkers and all levels of staff in a professional manner.
Familiarity and/or experience working with American Indian populations and respect for and knowledge of traditional, cultural, and spiritual practices of diverse American Indian communities, as well as an ability to work with other culturally and ethnically diverse populations.
Consistently demonstrate respect for and acceptance of differing capabilities, cultures, gender, age, sexual orientation, and/or personalities.
Maintain and ensure organizational privacy and confidentiality.
Must be able to handle crises and tolerate stress professionally.
Must be self-directed and take proactive initiative to assist others.
Possess the ability to resolve issues with other departments and coworkers without direct supervision.
Able to exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.
Ability to maintain a flexible work schedule, including evenings, weekends, and overnight or extended travel as necessary.
Ability to effectively present information in one-on-one and small group situations to community members, consumers, and other employees of the organization.
Proficiency with computer programs (Word, Excel, PowerPoint) and other Internet technologies.
Valid driver’s license must be kept current, and certificates, credentials, or licenses must be kept current and consistent with regulations required by applicable federal, state, and/or grant regulations.
Ability to promote an alcohol-, tobacco- and drug-free lifestyle.
Embrace modes of appearance and attire that reflect a professional presence.
Adhere to GPTLHB policies and procedures.
Associate degree and one (1) year of relevant administrative office support; or a high school diploma or equivalent and three (3) years of relevant administrative office support experience sufficient to understand the major duties of the position.
Demonstrated efficient organizational skills and successful completion of tasks under continuing pressure to meet deadlines.
Must successfully pass a criminal and background check and a pre-employment drug screen.
Compliance with our Employee Health Procedure is a condition of employment. You are required to agree that you will comply with all job-related employee health screening and immunizations prior to your first day of employment. Jobs require that you have documentation that you have completed the following immunizations prior to your first day of employment: MMR (Measles, Mumps and Rubella, Varicella (Chicken Pox), Hepatitis B, Influenza, T-dap (Tetanus - Diphtheria - Pertussis), and COVID-19 vaccination is required.

Nice To Haves

Purchase Referred Care experience
One (1) year coding experience

Responsibilities

Answers telephone and greets visitors; provides information and assistance; and resolves problems.
Gathers patient demographic information, updates patient information, and determines eligibility for services; and obtains documentation of Indian blood or other documentation of Tribal membership and proof of residency, when necessary.
Maintains, key-enters, updates, and verifies all Alternate Resources data necessary for patient registration and for accurate billing, and makes corrections as necessary to improve the Purchased Referred Care process.
Reviews UB-04 and CMS 1500 claim forms for accuracy and completeness.
Re-prices all clean claims utilizing appropriate software.
Communicates claims outcomes to vendors and patients.
Works with finance staff to ensure claims are paid in a timely manner.
Maintain effective communication techniques between PRC and outside vendors.
Save all repriced claims; be familiar with shared file methods and how to store, manage and share files.
Stay abreast of CMS changes in Fee Schedules and PC Price guidelines.
Provides reports in accordance with established schedule and format as requested.
Maintains an adequate supply of required forms/documents.
Participates in performance improvement teams and other committees as assigned.
Must comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPAA).
Performs related duties.