Purchased Referred Care (PRC) Claims Technici

About the role

This position involves repricing outside vendor claims according to federal guidelines and OHC PRC policies. Specific duties include answering the telephone, providing information and assistance, resolving problems, gathering patient demographic information, updating patient information, determining eligibility for services, obtaining documentation of Indian blood or Tribal membership, maintaining and key-entering data, reviewing claim forms, re-pricing claims, communicating outcomes to vendors and patients, working with finance staff, maintaining effective communication with vendors, saving and storing repriced claims, staying informed about CMS changes, providing reports, maintaining forms/documents, participating in performance improvement teams, and adhering to HIPAA.

Responsibilities

• Answers telephone and greet visitors; provides information and assistance; resolves problems.
• Gathers patient demographic information, updates patient information, and determines eligibility for services; 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.
• Saves all repriced claims; be familiar with shared file methods and how to store, manage and share files.
• Stays 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.
• Participate in performance improvement teams and other committees as assigned.

Requirements

• 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.
• Purchase Referred Care experience; Preferred One (1) year coding experience; Preferred Demonstrated efficient organizational skills and successful completion of tasks under continuing pressure to meet deadlines.

Qualifications

• Must successfully pass a criminal and background check and a pre-employment drug screen.
• The GPTCHB is a tribal organization which follows tribal preference laws. It is our policy to give preference to qualified Indian/Tribal candidates over qualified non-native candidates in hiring decisions, if all other qualifications are equal.

Benefits

Employment is contingent upon the outcome of all required criminal background checks and 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.

Skills

• Efficient organizational skills.
• Ability to communicate effectively with internal and external stakeholders.
• Ability to perform essential functions of the job with or without reasonable accommodation.

Pay

N/A

Schedule

N/A