Purchased Referred Care (PRC) Claims Technician

Job Summary: Primary responsibilities involve repricing outside vendor claims according to federal guidelines and OHC PRC policies.
This position uses the functions within RPMS, EHR and repricing software to analyze vendor claims and reprice them to Medicare-Like Rates.
Essential Functions: Answers telephone and greets visitors; provides information and assistance; and resolves problems.
Gathers patient demographic information, updates patient information, and determines eligibility for services; and 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.
Save all repriced claims; be familiar with shared file methods and how to store, manage and share files.
Stay 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.
Participates in performance improvement teams and other committees as assigned.
Must comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPAA).
Performs related duties.
Professional Behavior Effectively plan, organize workload, and schedule time to meet the demands of the position.
Work in a cooperative and professional manner with OHC and GPTLHB staff.
Treat Great Plains tribes and collaborators with dignity and respect.
Utilize effective verbal and written communication skills.
Advance personal educational development by attending training sessions and seminars as appropriate.
Exemplify excellent customer service with tribal stakeholders, health board colleagues, program partners, service recipients, visitors, and guests.
Foster a work environment of wellness, courtesy, friendliness, helpfulness, and respect.
Relate well and work collaboratively with coworkers and all levels of staff in a professional manner.
Consistently demonstrate respect for and acceptance of differing capabilities, cultures, gender, age, sexual orientation, and/or personalities.
Maintain and ensure organizational privacy and confidentiality.
Handle crises and tolerate stress professionally.
Be self-directed and take proactive initiative to assist others.
Resolve issues with other departments and coworkers without direct supervision if needed.
Exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.
Promote an alcohol, tobacco, and drug-free lifestyle.
Embrace modes of appearance and attire that reflect a professional presence.
Adhere to GPTLHB policies and procedures.
Requirements Exemplify excellent customer service with tribal stakeholders, health board colleagues, program partners, service recipients, visitors, and guests.
Foster a work environment of wellness, courtesy, friendliness, helpfulness, and respect.
Relate well and work collaboratively with coworkers and all levels of staff in a professional manner.
Familiarity and/or experience working with American Indian populations and respect for and knowledge of traditional, cultural, and spiritual practices of diverse American Indian communities, as well as an ability to work with other culturally and ethnically diverse populations.
Consistently demonstrate respect for and acceptance of differing capabilities, cultures, gender, age, sexual orientation, and/or personalities.
Maintain and ensure organizational privacy and confidentiality.
Must be able to handle crises and tolerate stress professionally.
Must be self-directed and take proactive initiative to assist others.
Possess the ability to resolve issues with other departments and coworkers without direct supervision.
Able to exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.
Ability to maintain a flexible work schedule, including evenings, weekends, and overnight or extended travel as necessary.
Ability to effectively present information in one-on-one and small group situations to community members, consumers, and other employees of the organization.
Proficiency with computer programs (Word, Excel, PowerPoint) and other Internet technologies.
Valid driver’s license must be kept current, and certificates, credentials, or licenses must be kept current and consistent with regulations required by applicable federal, state, and/or grant regulations.
Ability to promote an alcohol-, tobacco- and drug-free lifestyle.
Embrace modes of appearance and attire that reflect a professional presence.
Adhere to GPTLHB policies and procedures.
Supervisory Controls The supervisor provides continuing or individual assignments by indicating generally what is to be done, limitations, quality and quantity expected, deadlines, and priority of assignments.
When there are new, difficult, or unusual assignments, the supervisor provides additional, specific instructions for including suggested work methods or advice on source material available.
The employee uses initiative in carrying out recurring assignments independently without specific instructions but refers deviations, problems, and unfamiliar situations not covered by instructions to the supervisor for decision or help.
The supervisor reviews finished work to assure methods used are technically accurate and in compliance with instructions or established procedures.
Review of the work increases with more difficult assignments if the employee has not previously performed similar assignments.
Guidelines Guidelines are available but are not completely applicable to the work or have gaps in specificity.
The employee must use judgment in interpreting and adapting guidelines, such as agency policies, regulations, precedents, accreditation requirements, advanced clinical protocols, and work directions for application to specific cases or problems.
The employee analyzes results and recommends changes.
The employee uses initiative and resourcefulness in deviating from traditional methods or researching trends and patterns to develop new methods, criteria, or proposed new policies.
Complexity/Scope of Work The work consists of related steps, processes, or methods.
The decision regarding what needs to be done involves various choices that require the employee to recognize the existence of and differences among a few easily recognizable situations.
Actions to be taken or responses to be made differ in such things as the source of information, the kind of transactions or entries, or other differences of a factual nature.
The work involves the execution of specific rules, regulations, or procedures and typically comprises a complete segment of an assignment or project of broader scope.
The work product or service affects the accuracy, reliability, or acceptability of further processes, services, and/or patient care.
This level of scope and effect is typically representative of positions in which work performed may have minimal impact on the work of others within a defined process.
Contacts The personal contacts are with employees throughout the organization and are generally engaged in different functions and kinds of work and may be representatives from various levels.
Other personal contacts at this level include contact with partner organizations, Tribal affiliate organizations, and members of the general public.
The purpose is to obtain, clarify, or give facts or information regardless of the nature of those facts; i.
e.
, the facts or information may range from easily understood to highly technical.
Work Environment/Physical Demands The environment involves everyday risks or discomforts that require normal safety precautions typical of such places as offices, meeting and training rooms, requiring use of safe work practices with office equipment, avoidance of trips and falls, observance of fire regulations and traffic signals.
The work area is adequately lighted, heated, and ventilated.
The work is sedentary.
Typically, the employee sits comfortably to do the work.
However, there may be some walking; standing; bending; carrying of light items, such as papers, books, or small parts; or driving an automobile.
The employee must be able to read, write, speak and hear.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Supervisory and Management Responsibility This is a non-supervisory position that may provide functional direction, guidance, and instruction to other employees when necessary.
This position possesses the authority to assign, coordinate, and review the quality and quantity of work of other employees.
Instruct employees on specific techniques or technical methods for accomplishing work assignments.
The employee may perform the same type of work as other employees but may be responsible for the performance of the more technically difficult, controversial, or sensitive work assigned to the unit or group.
Minimum Qualifications 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.
Must successfully pass a criminal and background check and a pre-employment drug screen.
The GPTLHB 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.
Employment is contingent upon the outcome of all required criminal background checks.