Purchased Referred Care Claims Analyst

Navajo Preference Employment Act

In accordance with Navajo Nation law and applicable federal law, has implemented a Navajo/Indian Preference in Employment Policy. Pursuant to this Policy, applicants who are enrolled members of the Navajo Nation, Hopi Tribe, and San Juan Southern Paiute Tribe and who meet the necessary qualifications for this position will be given preference in hiring and employment for this position. Applicants who are legally married to an enrolled member of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe, who have resided within the territorial jurisdiction of the Navajo Nation or other federally recognized American Indian Tribe for at least one continuous year immediately preceding the date of application, and who meet the necessary qualifications for this position will be given secondary preference.

Applicants who are enrolled members of any other federally recognized American Indian Tribe and who meet the necessary qualifications will be given tertiary preference.

This position is considered an expert in Purchased Referred Care (PRC) and is a key resource for team members. The PRC Claims Analyst works closely with department leadership to monitor program compliance, budget, reports, and claims accuracy by performing the following: monitoring fund control and appropriate use of dollars spent on allowed services, auditing claims processed for patient eligibility for third party programs, and ensuring proper codes are submitted to cover primary provider, diagnosis, and clinic.

The PRC Claims Analyst performs high-cost case management of expenditures to determine cases that may include catastrophic illnesses; and performs repricing claims to Medicare Like Rates.

High School Diploma or GED

• Must have 5 years of general clerical experience that includes data entry and providing customer service.
• Must have 5 years of experience in clinical / medical setting.
• Must have 5 years of experience in PRC, Revenue Cycle, Patient Benefits in any combination or separately to equal the 5 years of experience.
• Must have 1 year of experience in budgeting to include assuring funds have been obligated within deadlines, maintaining weekly spending plan, processing claims for payment to vendors.
• Must have medical terminology course completion. Navajo Medical Interpreter certification may substitute for general medical terminology course completion.
• Experience in repricing PRC claims at Medicare Like Rates (will be clarified during interview process)

A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:

• Fosters teamwork and positive working relationships with others
• Possession of high ethical standards and no history of complaints
• Reliable and dependable; reports to work as scheduled without excessive absences.
• Effective communication skills to deal effectively with all levels of co-workers.
• Ability to multi-task, prioritize and manage time to strict deadlines.
• Must be proficient with typing and accurate spelling/grammar.
• Completion of an above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job.
• Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job.
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job.
• Submission of all required employment-related documents, application, resumes, references, and other required information free of false, misleading, or incomplete information, as determined by TCRHCC.

The physical and mental demands described here are representative of those that an employee should meet to successfully perform the essential functions of this job.…