CHS Claims & Payment Specialist - CHS - Okmulgee

Job Posting

The purpose of this position is responsible for review, adjudication and reimbursement of approved Purchased/Referred Care (PRC)/ Contract Health Services claims. This position serves as a critical financial and compliance role within the organization, ensuring responsible stewardship of tribal healthcare funds by verifying patient eligibility, coordinating benefits, exhausting alternate resources, validating medical claims, and processing payments in accordance with federal regulations, Indian Health Service guidelines, Muscogee Creek Nation polices, and healthcare reimbursement standards.

The incumbent exercise independent judgement in reviewing complex healthcare claims, identifying billing discrepancies, coordinating with providers and insurance carries, maintaining regulatory compliance, and supporting reimbursement initiatives including Catastrophic Health Emergency Funds (CHEF) Recoveries. Incumbent is supervised by the Claims/Payment Manager. It also has responsibility in conjunction with the coordination of the staff within Muscogee (Creek) Nation Department of Health Clinic CHS Coordinators.

Review, analyze, and process medical claims for payment in accordance with approved referrals, authorizations, eligibility requirements, and established reimbursement guidelines.

Verify accuracy of provider billing, coding, and supporting documentation prior to payment authorization.

Issues payments and checks to providers that have seen our patients with approved referrals/call-ins.

Receiving and processing incoming call regarding claim status or patient's bills

Apply Medicare-Like-Rates (MLR), contractual pricing methodologies, and established payment policies.

Identify billing discrepancies, duplicate claims, coding errors, and payment variances.

Maintain compliance with HIPAA, Privacy Act requirements, IHS regulations, CMS guidelines, and departmental policies.

Generate and process provider payments and reimbursement request in a timely manner.

Scans and distributes refund checks to appropriate parties.

Determine patient's eligibility utilizing internal eligibility systems and external verification resources.

Verify and coordinate benefits through Medicare, Medicaid, private insurance, and other third-party resources.

Review Explanation of Benefits (EOB) and insurance remittances to ensure alternate resources have been exhausted prior to expenditure of tribal healthcare funds/federal fund.

Protect tribal healthcare resources through detailed claim review and adherence to payment guidelines.

Generate reports, payments summaries, and supporting documentation as requested.

Participate in audits and quality assurance activities related to claims processing and payment accuracy.

Assist with identifying and documenting potential reimbursement to ensure alternate resources have been exhausted prior to expenditure of tribal healthcare funds.

Maintains exemplary attendance.

Generates and distributes claims inquiry letters and refund request letters.

Maintain and update claims data within the EHR and WADE, SPARC, EPIC and other healthcare information systems.

Ensure accurate documentation and record retention for all reimbursement activities.

Perform technical review and validation of referrals, authorizations, and payment records.

Serve as primary point of contact for providers inquiries regarding claim status, reimbursement, and payment resolutions.

Communicate effectively with healthcare providers, patients, insurance companies, and internal stakeholders.

Research and resolve claim-related issues while maintaining exceptional customer service standards.

To perform any other duties as requested, or as become evident.

Basic Accounting Principles, HIPPA Privacy Act Knowledge, Reporting Skills, Deadline-Oriented, Time Management, Attention to Detail, Confidentiality, PC Proficiency (MS Office Suite of Products), Productivity, Verbal Communication, General Math Skills, Customer Service, Team Player, Knowledge of Third-Party Administrator industry.

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.