CHS Claims & Payment Specialist - CHS - Okmulgee

Job Title

The purpose of this position is responsible for review, adjudication and reimbursement of approved Purchased/Referred Care (PRC)/ Contract Health Services claims.

Education – High School Diploma or GED equivalent is required. Associate Degree in Healthcare or Business Administration, Medical Billing and Coding, Accounting, or any related field preferred.

Experience – Minimum two (2) years of relevant experience in medical billing, healthcare claims processing, insurance verification, revenue cycle, Contract Health Service/Purchased Referred Care, third party healthcare billing or related field preferred.

Preferred Experience - Indian Health Service (IHS), Purchased Referred Care (PRC)/Contract Health Service (CHS), Medicare/Medicaid, Commercial Insurance Coordination, Medical Claims adjudication, and Electronic Health records (EHR).

Licenses & Certification – Must possess valid State of Oklahoma Driver's License and be insurable.

Knowledge & Skills –

• Knowledge of Contract Health Services (CHS), Indian Health Services (IHS) and Department of Health Administration Policies, regulations, and Procedures.
• Knowledge of healthcare reimbursement methodologies and claims adjudication.
• Knowledge of general medical terminology, CPT, HCPCS, ICD coding concepts and of the terminology used in the process of referrals.
• Ability to prioritize and complete multiple work assignments in a timely manner.
• Knowledge of HIPPA, Privacy Act, and medical record confidentiality requirements.
• Knowledge of Medicare, Medicaid, and commercial insurance billing practices.
• Ability to analyze complex billing and reimbursement information.
• Knowledge of healthcare financial management principles.
• Ability to identify payment discrepancies and billing irregularities.
• Ability to interpret healthcare regulations, policies, and reimbursement guidelines.
• Strong analytical and problem-solving skills
• Advance data entry and computer proficiency.
• Ability to manage multiple priorities in a high-volume healthcare environment.
• Ability to communicate courteously and effectively with patients and their families, MCNDH Staff and the general public via orally and in writing.
• Ability to maintain a professional demeanor and maintain strict confidentiality.

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.