TO Purchased Referred Care Technician

Sagchip; Mount Pleasant (MI); Hybrid; USD 42,000 - 65,000; Full time

Benefits offered by this job

16 paid holidays

Medical, Dental, Vision

401K with 4% match

Job summary

Saginaw Chippewa Indian Tribe, located in Michigan, seeks a CHS/PRC claims processor to manage referrals and insurance claims under Indian Health Services guidelines. The role emphasizes patient privacy, accurate billing, and coordination with tribal providers.

The candidate will handle outside provider denials, generate reports, and maintain billing records while ensuring timely submission of CHS claims and Tribal Supplement requests.

Qualifications

• High school diploma or GED is required.
• Experience with medical billing and insurance is preferred.
• Basic knowledge of HIPAA rules and patient confidentiality.
• Strong telephone and written communication skills.
• Ability to manage multiple referrals and deadlines.

Responsibilities

• Prepare and submit CHS/PRC insurance claims according to IHS guidelines.
• Educate Tribal Members about CHS eligibility and policies.
• Review external provider claims for accuracy of co-pays and deductibles.
• Ensure claims are processed correctly by carriers and update billing systems weekly.
• Maintain and update the PRC billing system and patient files.

Skills

Billing knowledge

HIPAA compliance

MS Office

Customer service

Communication skills

Data entry

Attention to detail

Education

High School Diploma or GED

Tools

Intergy

Ariett

Microsoft Office

Billing software

Job description

Eligible Employer for Public Student Loan Forgiveness as a non-profit

SCIT recognizes that work-life balance is essential in day to day operations. Our Flexible Schedule and Telework options for employees make it possible to balance the needs of your family while still being on track at work. Flexible Schedule and Telework options are based on the departments need. The Tribe is a community based organization and we understand your family life is important, it’s important to us too.

Here are some of the benefits our team members get working for the Tribe: 16 Paid Holidays off include: New Year’s Day, M.L. King Jr. Day, President's Day, Easter Monday, Memorial Day, Juneteenth, Independence Day, SCIT National Holiday, Labor Day, Michigan Indian Day, Veteran's Day, Thanksgiving, Christmas Eve, Christmas Day and New Year’s Eve. We never miss those special moments with our children, family & friends due to working.

Our paid time off accruals for annual and sick leave are as followed: 0-3 years of service = 2 hours of annual & sick per 40 hours worked; 3-9 years of service = 3 hours of annual & sick per 40 hours worked; 10 years or more of service = 4 hours of annual & sick per 40 hours worked. Plus you get 16 hours of personal time per calendar year (prorated based on your start date, resets every Jan.1). We also have Bereavement, Longevity, Fitness, and maternity/paternity leave.

Full Time employees get Medical, Dental, & Vision insurance. Flex Spending accounts, Teladoc, life insurance, accidental death, Long Term Disability, Aflac, and 401K which SCIT matches up to 4%.

Prescription plan with free fills on most generic brands when using our Cardinal Pharmacy.

Position Summary:

• Under the supervision of Business Office Director, work closely with the medical and dental departments to ensure patient referrals are within the Contract Health services (CHS) guidelines. Responsible for preparing, processing and submitting weekly Indian Health “payor of last resort” insurance claims according to Indian Health Services, Contract Health (PRC) guidelines and bi-weekly Tribal Supplement check requests. Responsible for the maintenance and education of the program to Tribal Members in the Contract Health Service Delivery Area (CHSDA) in accordance with Indian Health Services regulations. All Nimkee staff must adhere to mandated reporting laws.

Essential Duties and Responsibilities:

• Answer questions and provide assistance to patients and other clients about Contract Health Services policies, process and eligibility.
• Return phone calls and provide assistance and information to patients or providers.
• Review and assure that claims from outside providers are accurate, such as co-pays and deductibles.
• Ensure medical claims have been processed correctly by insurance carriers.
• Manage the authorization process for referrals in the system.
• Prepare and authorize services for outside providers following IHS medical priority.
• Deny claims from outside providers due to patients not following policy. Submit denial letters to vendors and patients via certified mail while keeping updated denial reports in Intergy.
• Maintain the Purchased Referred Care (PRC) computerized billing system in Intergy for all internal modes of communication; processing payments within the systems to vendors and providers; updating billing systems weekly; updating billing records and patient`s files.
• Create patient`s referrals to other appropriate agencies coordinated through the Saginaw Chippewa Indian tribal entities.
• Assure the utilization and coordination of resources/services such as: Saginaw Chippewa Tribe`s health insurance, Medicaid, Nimkee Memorial Wellness Center, department of Social Services, and other health insurances.
• Maintain and update billing systems weekly; update billing records and patient files.
• Review and approve optical appointments if eligible.
• Maintain a daily log for Optical, Pharmacy, DME, and Diabetic Shoes.
• Maintain accurate contact information for established vendors and complete the appropriate paperwork to register a new vender in the Ariett system.
• Review the Optical patient list, check eligibility per Nimkee Optical policy and update patient information in Intergy scheduling package.
• Submit weekly/monthly reports to administration and other departments.
• Correct refunds from providers; make deposits accurately for Tribal Accounting/Accounts Payable.
• Approve patient DME`s and Rx requests, approve per eligibility status.
• Keep administration and PRC Technicians updated on all changes with insurance carriers and providers.
• Analyze all open referrals and call providers to complete the payment process or verify claim status.
• Provide updates for all health providers, vendors and the tribal community on any changes concerning IHS, tribal and federal legislation policies regarding the Purchased/Referred Care program.
• Update all year end reports and changes for that occurred.
• Prepare and submit all required reports to IHS.
• Mandatory participation on the Managed Care Committee while following through on all active cases.
• Abide by the PRC work schedule with other co-works, finish work within a timely manner and submit CHS claims weekly and Tribal Supplement bi-weekly.
• Adhere to patient confidentiality and comply with clinic policies and federal regulations under the Privacy rules of the Health Insurance Portability and Accountability Act (HIPAA).
• Provide excellent customer service for all internal and external customers of the operations at all times. Provide solutions for customer concerns and continually focus on customer service as our top priority.
• Must maintain strict confidentiality and present a positive, professional demeanor and image at all times.
• The above duties and responsibilities are not an all-inclusive list but rather a general representation of the duties and responsibilities associated with this position. The duties and responsibilities will be subject to change based on organizational needs and/or deemed necessary by the supervisor.

Contacts/Purpose of Contacts:

• Contact with staff, managers and outside sources including doctors` offices, insurance carriers and other appropriate agencies to obtain and provide information.
• Contact with patients to assist in obtaining services.

Minimum Qualifications:

• High School Diploma or GED.
• Must be 18 years of age.
• Must have previous office experience.
• Good written and communication skills.
• Proficient with Microsoft Office Suite of software.
• Must be able to pass background check to meet the employment eligibility requirements as they pertain to the position.

Desired Qualifications:

• Experience with insurance carriers.

License, Certification, or Special Requirements:

• Ability to obtain HIPAA Certification, Blood Borne Pathogens Certification, and Safety Training within thirty days of hire.
• Native American preference shall apply to all positions.

Knowledge, Skills, and Abilities:

• Knowledge of applicable federal, state, county and local laws, regulations, and requirements, including patients` rights and confidentiality.
• Knowledge of PRC functions, objectives, policies and procedures.
• Knowledge of billing requirements, Medicaid, Medicare, Worker`s compensation and other insurance programs.
• Knowledge of CPT-4, ICD-10, HCPCS and CDT coding.
• Skill in operating business computers and office machines, including in a Windows environment, specifically Word, Excel, Access, and PowerPoint.
• Ability to understand and interpret vendor invoices, statements, insurance Explanation of Benefits (EOBs), and other requests for payment.
• Ability to communicate effectively both verbally and in writing.
• Ability to verify data input and correct errors.
• Ability to gather data, compile information, and prepare reports.
• Ability to use independent judgment and to manage and impart confidential information.
• Ability to interact and maintain good working relationships with individuals of varying social and cultural backgrounds, employees and officials.
• Ability to represent the organization in a professional manner, building respect and confidence.
• Ability to understand and follow oral and written instruction.
• Ability to analyze and solve problems.
• Ability to maintain confidentiality.

Physical Demands:

• Frequent use of hands, wrists, fingers associated with computer equipment.
• Frequently require to reach with arms and hands.
• Required to sit for extended periods of time.
• Occasionally walk and stand, climb, balance, stoop, kneel, crouch or crawl.
• Normal visual acuity, ability to talk and hear.
• Occasionally lift and/or move up to 20 pounds.
• Medical Clinic and normal office environment.
• Extended hours and irregular shifts may be required.
• Travel may be required.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.