Purchased Referred Care (PRC) Claims Technici in Rapid City, South Dakota at Great Plains Tribal Leaders Health Board Inc
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Job Description
Position Title: Purchase Referred Care Claims Technician
Division: Oyate Health Center
Reports To: Purchased Referred Care Manager
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.
Specific duties include, but are not limited to:
- Answers telephone and greet 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.
- Participate 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.
- Performs the core responsibilities of the position accurately, timely, and in accordance with established standards.
- Maintains regular and reliable attendance consistent with the position’s schedule and operational needs.
- Communicates effectively with internal and external stakeholders as required by the role.
- Adheres to all applicable policies, procedures, and regulatory requirements.
- Utilizes required systems, tools, and technology necessary to perform the job.
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 GPTCHB is a tribal organization which follows tribal preference laws. It is our policy to give preference to qualified Indian/Tribal candidates overqualified non-native candidates in hiring decisions, if all other qualifications are equal
Employment is contingent upon the outcome of all required criminal background checks and pre-employment drug screen.
Compliance with our Employee Health Procedure is a condition of employment. You are required to agree that you will comply with all job-related employee health screening and immunizations prior to your first day of employment. Jobs require that you have documentation that you have completed the following immunizations prior to your first day of employment: MMR (Measles, Mumps and Rubella, Varicella (Chicken Pox), Hepatitis B, Influenza, T-dap (Tetanus - Diphtheria - Pertussis), and COVID-19 vaccination is required.
This position requires the ability to perform the essential functions of the job, with or without reasonable accommodation. Physical demands and work environment may include:
• Primarily sedentary work is performed in an office or administrative setting.
• Requires the ability to sit for extended periods and regularly use standard office equipment such as a computer, keyboard, telephone, and copier.
• Occasional standing, walking, bending, and reaching may be required.
• Ability to lift and carry office materials or supplies up to 25 pounds occasionally.
• Requires manual dexterity and visual acuity for computer use and document review.
• Must be able to read, write, speak, and hear.
• Work is performed primarily in an indoor office or administrative environment.
• The environment involves everyday risks or discomforts that require normal safety precautions typical of office settings, including proper use of office equipment and awareness of trips, falls, and fire regulations.
• The work area is adequately lighted, heated, and ventilated.
• Minimal exposure to hazardous conditions; no routine exposure to clinical, field, or high risk environments.
• Occasional attendance at meetings, training sessions, or events may require travel within the organization's facilities.
The employee must comply with all organizational policies, procedures, and applicable laws and regulations. This position is subject to Native Preference, background checks, health requirements, and other applicable organizational standards.