CHS/PRC Claims Specialist

Nisqually Indian Tribe; Olympia (WA); On-site; USD 31,000 - 44,000; Full time

Job summary

Nisqually Indian Tribe is seeking a PRC/CHS Claims Specialist to support the Health & Wellness Center, coordinating care and managing benefits and approvals under IHS eligibility guidelines.

The role emphasizes prompt financial processing, billing support, and cross-functional interaction with patients, providers, and staff to ensure accurate reimbursement and service delivery.

Qualifications

• Graduation from high school or equivalent.
• Three years' experience in a Purchased Referred Care or Contract Health Service program or IHS program specific to Tribal Health services.
• Three years' experience processing all types of health/dental claims.
• Two years in depth knowledge of all aspects of benefits & claims processing.
• Two years successful customer service background.

Responsibilities

• Ensure that all Indian Health Contract Health Service requirements are met for all eligible clients/patients and assists in all necessary daily operations of the CHS program.
• Administer contracted health care to eligible clients/patients according to the IHS federal guidelines, and the programs Policy & procedures, as well as federal rules/regulations based on annual funding.
• Responsible for assuming dual responsibility for processing routine and complex health claims as well as providing customer service to both patients and providers.
• Serve as a resource for clients/community members and other Nisqually Tribal Health & Wellness Center staff.
• Conduct a majority of their workday with face to face and phone contact with PRC/CHS eligible clients issuing authorizations for medical care.

Education

High school diploma or equivalent

Three years' experience in PRC/CHS or IHS programs

Three years' experience processing health/dental claims

Two years in-depth knowledge of benefits & claims processing

Two years customer service background

Job description

Please note: NSORNA Nisqually's Sex Offender Registration and Notification Act requires all individuals who have ever been convicted of a sex offense to register with our Public Safety Department. This is true whether or not you have to register with another jurisdiction.

This position has regular contact with or control over Indian Children and Vulnerable Adults. In compliance with Federal Law, this position will not be filled by an applicant with any felonious offense or any of two or more misdemeanor offenses under Federal, State, or Tribal law involving crimes of violence; sexual assault, molestation, exploitation, contact, or prostitution; crimes against persons; or offenses committed against children.

General Summary

Working with a motivated Business Office Staff focused on providing access and support of specialty referred care from a Health and Wellness Center environment, by way of coordination of care, management of benefits, approvals of services based on IHS eligibility guidelines, to provide the best customer service and assistance to the population that we serve. Our responsibility is to assure prompt, accurate financial processing, and reporting for our financial obligations.

Primary Responsibilities

Primary responsibilities are the basic job duties that an employee must be able to perform. This list of responsibilities is intended to be representative of the duties performed within this classification. The omission of a function does not preclude management from assigning duties not listed if such duties relate to the position.

Job Duties

• Ensure that all Indian Health Contract Health Service requirements are met for all eligible clients/patients and assists in all necessary daily operations of the CHS program.
• Administer contracted health care to eligible clients/patients according to the IHS federal guidelines, and the programs Policy & procedures, as well as federal rules/regulations based on annual funding.
• Responsible for assuming dual responsibility for processing routine and complex health claims as well as providing customer service to both patients and providers.
• Serve as a resource for clients/community members and other Nisqually Tribal Health & Wellness Center staff.
• Conduct a majority of their workday with face to face and phone contact with PRC/CHS eligible clients issuing authorizations for medical care.
• Assists in assuring patient eligibility meets the IHS/PRC guidelines. Verifying all alternative medical insurance resources are utilized prior to providing PRC services.
• Generating Purchase Order numbers (PO) through the current PRC operating system, for patients requesting via telephone or in person.
• Matching Explanation of Benefits (EOB) to existing Purchase Orders (PO)
• Verify and document the status of each individual existing Purchase Orders (PO), for completion of the billing process, and to assure payments are made in a timely manner.
• Work with off-site Specialty Providers inquiring about referrals, and services related to physician visits, laboratories, pharmacies, dental providers, and patients via mail or in person.
• Works daily with invoicing of PRC/CHS claims, and the posting of payments.
• Provide answers to referring physicians, and those responsible for their billing, when inquiring about payment status.
• Open and sort incoming correspondence.
• Participates in seminars and meetings that relate to Purchase Referred Care/Contract Health Services.
• Filing and other common clerical duties.

Safety

• Adheres to safety policies and procedures within the Nisqually Health & Wellness program.
• Reports inappropriate incidents by filing incident reports and forwarding the report to their immediate supervisor.
• Respond to emergencies in a calm and professional manner and report to designated area and or person in case of an emergency.

Communication

• Represents the Nisqually Tribal Health & Wellness Center in a positive and professional manner when interacting with patients and the community.
• Demonstrate positive interpersonal relations skills in dealing with staff, providers, and management.
• Consistently maintains confidentiality and follows HIPAA guidelines, on behalf of the patient and the organization.
• Participates in staff meetings.

MINIMUN QUALIFICATIONSEducation and Experience

• Graduation from high school or equivalent.
• Three years' experience in a Purchased Referred Care or Contract Health Service program or IHS program specific to Tribal Health services.
• Three years' experience processing all types of health/dental claims.
• Two years in depth knowledge of all aspects of benefits & claims processing.
• Two years successful customer service background.

Preferred Qualifications

• Experience in a Tribal PRC/CHS Program
• Experience in medical billing in both ambulatory and hospital settings.
• Experience and knowledge of state, federal and private insurances.
• A strong understanding and knowledge of private, state, and federal health insurance practices as it pertains to processing patient in-coming claims.
• Flexible, self-motivated, independent, detailed oriented and reliable.
• Experience in customer service.
• Knowledgeable in CPT and ICD-10 billing codes.
• Knowledge of medical terminology.
• Ability to communicate effectively both oral and written.
• Dependable and prompt.

Salary: $26.90 per hour