Here’s what you’ll be doing:
Analyzes and processes minimum of 200 claims daily to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims
Analyzes and processes minimum of 400 claims to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims
Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations
Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations
Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments
Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments
Assists with other research and development projects as directed by Management; obtains and maintains necessary certification for Health Insurance Marketplace CAC
Provides training and guidance through expert knowledge of claims administration and adjudication to Insurance Department staff; responsible for the timely response to formal appeals from members, employees, clients and providers
Reviews, resolves and/or escalates Level 2 claims appeals; releases claims up to the designated draft authority for Level 2 Claims Examiner
Works with the Customer Service Coordinator to manage and provide direction to the utilization review and case management vendor; identifies and manages claims with potential subrogated recovery
Ensures that claims adjudication complies with all FCPID standards and protocols; reviews claims for possible abuses and/or fraud and bring to the attention of management
Oversees the repricing processes to ensure the integrity of the product; investigates claims referred by staff for possible abuse and fraud
What you’ll need to be successful:
High School Diploma or GED
High School Diploma or GED
Five (5) years of experience in medical claims processing
Five (5) years of experience in medical claims processing
Three (3) years in customer service
Three (3) years in customer service
Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards
Two (2) years in a lead or supervisory capacity
Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology
Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards
Knowledge of insurance principles and/or procedures
Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology
Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment
Knowledge of insurance principles and/or procedures
Must successfully pass all applicable background checks and drug screens
Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment
Must successfully pass all applicable background checks and drug screens
Benefits you’ll love:
- Approximately 5 weeks of paid time off annually
- 3 weeks of paid holidays
- Premium free health insurance
- Flexible spending accounts
- Short term disability
- Life insurance
- 401k with match
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.
