Fort Defiance
Indian Rte 7 & Indian Rte 12
PO Box 649
Fort Defiance, AZ 86504, USA
APPLICANT MUST HAVE A VALID, UNRESTRICTED INSURABLE DRIVER'S LICENSE RESUMES AND REFERENCES ARE REQUIRED ESSENTIAL DUTIES, FUNCTIONS AND RESPONSIBILITIES: Processes medical claims for services rendered to PRC eligible patients to process payment for services rendered. Reviews requests for healthcare referrals in accordance with established medical necessity/priority, PRC eligibility and payer criteria.Prepares, maintains and updates files inclusive of billing records, remittance advices, and related documents to process payments.Reviews and calculates the Medicare Like Rates (MLR) and fees (i.e. facility, professional, etc.) for medical services rendered through outpatient claims for all hospitals. Calculates medical charges using the Centers for Medicare/ Medicaid Services (CMS) system online.Initiates requests for appropriate documents and records needed to facilitate adjudication of claims. Adjudicates health insurance claims for payment through the PRC Program by verifying beneficiary eligibility and identification of alternative funding sources.Reviews and calculates Diagnosis Related Group (DRG) claims and repricing on all inpatient claims for all hospitals.Works closely with the accounts payable team to process payments to vendors and providers. Assists with posting payments made to vendors or providers in CHSMS (Purchased/Referred Care); ensures accurate posting of payments to correct accounts.Issues and verifies purchase orders for accuracy. Retrieves new and updated W-9s for Providers/Vendors and submits to Finance for updating in the accounting software.Runs the open document reports and reviews purchase orders with providers. Reviews purchase orders with claims and processing for payments; and works with providers to resolve discrepancies related to payments.Familiarity with variety of claim forms; including but not limited to, Explanation of Benefits (EOB), Catastrophic Health Emergency Fund (CHEF) claims and cases, and Finance payment processing forms.Participates in departmental orientation, on the job training and quality assurance programs/initiatives. Participates in a variety of department and hospital educational programs to maintain and/or advance current skills and competency levels; identifies and discusses performance or training needs with supervisor.Performs other duties as assigned.MANDATORY MINIMUM QUALIFICATIONS: Experience: One (1) year of experience in processing insurance claims.
Education: High School diploma or General Equivalency Diploma (GED).
Its facilities are located within the Navajo Nation and, in accordance with Navajo Nation law, has implemented a Navajo/Indian Preference in Employment Policy. Pursuant to this Policy, applicants who meet the minimum qualifications for this position and who are enrolled members of the Navajo Nation will be given primary preference in hiring and employment for this position and members of other federally recognized Indian tribes will be given secondary preference. Other candidates will be considered only after all candidates entitled to primary or secondary preference have been fully considered.
QualificationsSkillsBehaviorsMotivationsEducationRequiredHigh School or better.
ExperienceRequired1 year:One (1) year of experience in processing insurance claims.
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