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Healthcare Claims Coordinator

2 months ago

Rapid City, South Dakota, United States Great Plains Tribal Leaders Health Board Inc Full time
Job Overview

Position Summary:

This role involves the initiation, monitoring, and processing of health insurance claims under the "payer of last resort" policy, adhering to the guidelines set forth by United Indian Health Services (UIHS) for Contract Health Services (CHS). A comprehensive understanding of Purchased Referred Care services and alternative resources is essential, including private insurance and Medicare/Medicaid programs. Familiarity with the Affordable Care Act (ACA) and funds management techniques for Purchased/Referred Care services is also required, alongside specialized medical terminology knowledge.

Key Responsibilities:

  • Maintain accurate records for Contract Health Services.
  • Assess incoming referrals to ensure alignment with UIHS approved priorities.
  • Prepare and manage referrals requiring medical and dental evaluations.
  • Evaluate client eligibility and facilitate referrals to alternative resources when applicable.
  • Coordinate with external providers to arrange appointments for approved cases, request cost estimates, and inform clients of scheduled visits. Generate purchase orders for eligible referrals.
  • Engage with external agencies and clients regarding claim submissions.
  • Provide updates to clients and providers about the status of Contract Health Services claims.
  • Collaborate with UIHS providers to clarify referrals and address case inquiries.
  • Track the progression of Contract Health Services cases from appointment scheduling to final claims payment.
  • Manage claim reimbursements through Contract Health Services.
  • Prepare and submit cases for the Catastrophic Health Emergency Fund (CHEF) in accordance with IHS guidelines.
  • Respond to inquiries regarding PRC services through various communication methods, providing consultation to resolve issues.
  • Ensure compliance with federal regulations, including HIPAA.
  • Perform additional related duties as required.

Professional Conduct:

  • Effectively organize and prioritize workload to meet job demands.
  • Collaborate professionally with colleagues and stakeholders.
  • Show respect and dignity towards Great Plains tribes and partners.
  • Utilize strong verbal and written communication skills.
  • Engage in ongoing professional development through training and seminars.
  • Deliver exceptional customer service to all stakeholders.
  • Promote a workplace culture of wellness, respect, and collaboration.
  • Demonstrate respect for diverse backgrounds and perspectives.
  • Maintain confidentiality and privacy within the organization.
  • Manage stress and crises in a professional manner.
  • Take initiative to assist colleagues proactively.
  • Resolve interdepartmental issues independently when necessary.
  • Adapt to changing situations while maintaining a positive work environment.
  • Encourage a drug-free lifestyle among peers.
  • Present a professional appearance in accordance with organizational standards.
  • Adhere to organizational policies and procedures.

Qualifications:

  • Demonstrated commitment to excellent customer service.
  • Experience working with American Indian populations and understanding of their cultural practices.
  • Ability to respect and accommodate diverse backgrounds and perspectives.
  • Proficient in managing stress and crises effectively.
  • Self-motivated with the ability to work independently.
  • Flexibility to adjust plans as needed while maintaining productivity.
  • Willingness to maintain a flexible work schedule, including potential travel.
  • Strong presentation skills for small group and individual interactions.
  • Proficient in Microsoft Office Suite and other relevant technologies.
  • Valid driver's license and necessary certifications must be maintained.
  • Commitment to promoting a drug-free lifestyle.
  • Professional appearance and adherence to organizational standards.

Supervision:

Work is assigned with general instructions, and completed tasks are reviewed for compliance and appropriateness through discussions and observation.

Guidelines:

Guidelines include state and federal laws, organizational policies, and IHS PRC guidelines, requiring judgment and interpretation in their application.

Work Complexity:

This position encompasses various administrative and technical responsibilities aimed at supporting the PRC Program's operations.

Contact:

Interactions typically involve patients, healthcare staff, and external providers, primarily for the exchange of medical information to facilitate care.

Work Environment:

The role is primarily office-based, requiring sitting, standing, and occasional lifting of light objects. Reasonable accommodations will be made for individuals with disabilities.

Education and Experience:

  • High school diploma or equivalent.
  • Three years of administrative support experience, including one year in purchased referred care, preferably in a healthcare or customer service setting.
  • Successful completion of a criminal background check and drug screening is required.

Note:

This job description is not a contract of employment and is subject to change.