Medical Claims Specialist

Pay Range:$25.00 - $28.45 Under the direction of the Director of Purchased/Referred Care (PRC), the Medical Claims Specialist is primarily responsible for timely and accurately processing/payment of medical claims into the PRC claims processing package while providing excellent customer service to claimants and vendors. Maintains good vendor relations, works closely and follows up with accounts payable while maintaining compliance with all Federal, State, Tribal Health, and SEARHC PRC guidelines and regulations.

Must work independently making judgment calls when supervisor is not available. Position requires the ability to sit for long periods of time in front of a computer terminal. Mental fatigue exists with the high level of concentration necessary to properly process medical claims for payment accurately and timely. The employee must be able to work under stressful conditions. The PRC office maintains copies of each individual patient record as required by law and SEARHC policy and this position ensures that requirement is met. May occasionally encounter verbal abuse from customers or family members.

SEARHC is a non-profit health consortium which serves the health interests of the residents of Southeast Alaska. We see our employees as our strongest assets. It is our priority to further their development and our organization by aiding in their professional advancement.

Working at SEARHC is more than a job, it’s a fulfilling career. We offer generous benefits, including retirement, paid time off, paid parental leave, health insurance, dental, and vision benefits, life insurance and long and short-term disability, and more.

Key Essential Functions and Accountabilities of the Job

• Clerical duties such as answering phone, greeting patients and visitors, sending/receiving faxes, responsible for incoming and outgoing mail and responsible for security of all these forms of communication for patient confidentiality. Responsible for maintaining files including purging and shredding documents as needed and initiating and processing of denial and other letters as delegated by lead medical claims specialist. Review and screen all medical and dental claims from PRC health care providers. This requires verifying that the patient on claim is in our system using Cerner.

• Performs alternate health resource verification.

  Responsible for providing new or updated demographic information and any alternate health resource information to Patient Access.

  Review claims to determine if a referral is on file.

  Coordinate with Patient Access department to generate a new health record for patients who are in outlying areas and have not previously registered at SEARHC.

  Establish patient eligibility according to established policies and procedures.

  Review ICD, CPT, and revenue codes to determine if diagnosis and treatment are authorized as part of the initial referral.

• Management of data into the PRC claims processing program so that vendors can be paid timely. Process claims, using Medicare-like Rates when appropriate, for patients authorized to receive health services from facilities and providers outside of SEARHC.

• Coordinate quarterly with CMS to obtain current Medicare-like Rates for non-tribal facilities.

  Perform insurance verification on each eligible beneficiary, review procedure and diagnosis codes to determine if services are covered under the SEARHC and Federal guidelines for reimbursement.

  Research unauthorized claims and take appropriate action.

  Provide alternate health resource information to private providers and facilities for all referred patients.

• Provides assistance to customers regarding referrals and/or claim status, payment, patients admitted to non-tribal facilities, outstanding charges, and eligibility. Initiates, enters/update patient eligibility according to established procedures and Federal guidelines. Interpret PRC Program regulations, policies, and procedures to internal and external customers. Perform other duties as assigned.

Additional Details:

Education, Certifications, and Licenses Required

• High school diploma or equivalent.

• Medical terminology course required or 1 year of documented experience in a medical field requiring consistent use of medical terminology.

Experience Required

• 1 year of data entry experience with basic knowledge of accounts payable processing, MS Excel, and MS Word software applications.

• 3 years of business or medical office experience OR an equivalent combination of education and experience.

• Medical coding background preferred.

Knowledge of

• State, federal, and tribal health care programs.

• Medical insurance process.

• ICD and CPT coding.

Skills in

• Interpreting state, federal, and tribal contract health care guidelines.

• Research and problem solving.

• Oral/written interpersonal communication and excellent customer service skills.

Ability to

• Ability to multitask.

• Ability to enter large volumes of data timely and accurately.

• Ability to work independently with minimal supervision.

• Ability to respond quickly in urgent situations with attention to detail.

Position Information:

Work Shift:OT 8/40