Purchased Referred Care Claims Analyst

In accordance with Navajo Nation law and applicable federal law, preference in hiring and employment for this position will be given to applicants who are enrolled members of the Navajo Nation, Hopi Tribe, and San Juan Southern Paiute Tribe, as well as those legally married to enrolled members who meet residency requirements, and enrolled members of other federally recognized American Indian Tribes.

About the Role

This position is considered an expert in Purchased Referred Care (PRC) and serves as a key resource for team members. The PRC Claims Analyst works closely with department leadership to monitor program compliance, budget, reports, and claims accuracy. Responsibilities include monitoring fund control, auditing claims for patient eligibility, ensuring proper coding, performing high-cost case management, and repricing claims to Medicare Like Rates.

Responsibilities

• Welcome and greet patients/visitors in person and/or by telephone; answer or refer inquiries; direct patients/visitors; document calls and visits into PRC management software; record and deliver messages to appropriate personnel.
• Politely communicate with respect to patients and families during times of emotional, mental, and physical stress.
• Receive, date-stamp, and review daily patient referrals/notifications from patients, TCRHCC providers, and/or other facilities to determine PRC eligibility.
• Make independent decisions confidently and support decisions/actions taken regarding referral approval or denial.
• Notate referral approval/denial status to clinic providers or clinic CST staff; follow up on referrals to obtain appointment date and time; mail referral and PRC letter to patients.
• Forward referrals for non-TCRHCC patients to the appropriate service unit within 72 hours of receipt.
• Identify notifications and attach appropriate cover sheets with supporting documentation (e.g., TCRHCC Patient Face Sheet, AHCCCS verification forms, alternate resources, claims, medical notes).
• Compile documents, input data into the system to establish case records, and obtain referrals.
• Research electronic health records (EHR) to identify existing records and prevent duplication; note case numbers for quick referencing.
• Perform daily data entry of referrals/notifications into PRC management software; establish patient records and process claims.
• Educate patients/clients on the PRC scheduling process, rules, regulations, eligibility, and policies/procedures; conduct periodic reviews for timely follow-up.
• Interview patients and/or family members to determine potential eligibility for alternate resources; make necessary contacts and document actions taken.
• Administer day-to-day PRC program activities, including initiating medical purchase orders/claims payments within specified time limits.
• Maintain files of all correspondence for future confirmation and referencing; provide information to HIM for accidental injuries and Tort Claims.
• Maintain professional skills by attending in-services, workshops, and continuing education.
• Maintain a weekly spending plan within the PRC allocated budget; assist with reports on cases, claims, and expenditures.
• Review determinations and claims for accuracy; report discrepancies and make corrections as needed.
• Work closely with the Care Coordination Team to ensure continuity of patient care; update team members and attend department huddles.
• Collaborate with PBC staff to connect patients to alternate resources.
• Monitor program compliance, budget, reports, and claims accuracy; audit claims for patient eligibility and proper coding.
• Perform high-cost case management of expenditures, including catastrophic illnesses.
• Reprice claims to Medicare Like Rates.
• Ensure proper PPE is worn at all times, including face masks, gloves, gowns, N95 respirators, and eye/face shields.
• Complete donning and doffing tasks safely; discard used PPE appropriately.
• Complete routine cleaning and decontamination processes for surfaces contaminated by communicable diseases.
• Perform other duties as assigned.

Requirements

• High School Diploma or GED.
• 7 years of general clerical experience, including data entry and customer service.
• 7 years of experience in a clinical/medical setting.
• 7 years of combined experience in PRC, Revenue Cycle, or Patient Benefits.
• 3 years of experience in budgeting, including assuring funds are obligated within deadlines, maintaining weekly spending plans, and processing claims for payment.
• Completion of a medical terminology course (Navajo Medical Interpreter certification may substitute).
• Experience in repricing PRC claims at Medicare Like Rates (clarified during the interview process).

Skills and Abilities

• A record of satisfactory performance in all prior and current employment, as evidenced by positive employment references.
• Fosters teamwork and positive working relationships with others.
• Possession of high ethical standards with no history of complaints.
• Reliable and dependable; reports to work as scheduled without excessive absences.
• Effective communication skills to deal with all levels of co-workers.
• Ability to multi-task, prioritize, and manage time to meet strict deadlines.
• Proficient with typing and accurate spelling/grammar.
• Above-satisfactory scores on all job interviews, demonstrating the ability to perform essential job functions.
• Successful completion of background and reference checks, including fingerprint clearance, physical examinations, and other screenings.
• Submission of all required employment-related documents free of false, misleading, or incomplete information.

Mental and Physical Effort

The physical and mental demands described are representative of those required to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.

• Physical: Work is mostly sedentary with prolonged sitting, frequent reaching, and occasional standing, walking, driving, bending, climbing, kneeling, crouching, and twisting. Must be able to occasionally lift and pull over 100 lbs. Sensory requirements include prolonged near vision, color vision, depth perception, seeing delicate details, hearing normal speech, using the telephone, and occasional far vision and hearing overhead pages.
• Mental: Handle problems and deviations in accordance with established instructions, priorities, policies, and program goals. Must cope with high levels of stress, make decisions under pressure, handle anger/fear/hostility calmly, concentrate, demonstrate flexibility, manage multiple priorities, and work in close/crowded areas. Frequently work alone and occasionally manage altercations.

Environmental Conditions

• Occasional exposure to infectious diseases, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises.