ANMC Medical Claims Specialist I, II, III - (Salary: DOE)

Salary: Negotiable :USD

The Alaska Native Tribal Health Consortium is a non-profit Tribal health organization designed to meet the unique health needs of Alaska Native and American Indian people living in Alaska. In partnership with the more than 171,000 Alaska Native and American Indian people that we serve and the Tribal health organizations of the Alaska Tribal Health System, ANTHC provides world-class health services, which include comprehensive medical services at the Alaska Native Medical Center, wellness programs, disease research and prevention, rural provider training and rural water and sanitation systems construction.

ANTHC is the largest, most comprehensive Tribal health organization in the United States, and Alaska’s second-largest health employer with more than 3,100 employees offering an array of health services to people around the nation’s largest state.

Our vision: Alaska Native people are the healthiest people in the world.

Benefits include:

• Generous Paid Time Off and holiday schedule with 4 weeks paid vacation per year to start and 12 paid holidays.

• More than 19 Federal healthcare plans with plans for employee, employee plus one, and employee plus family available. ANTHC covers 80% of all health insurance premiums and 100% of Short-Term Disability, Long-Term Disability, Dental, Vision, Basic Life, and AD&D.

• 401(a) retirement plan; ANTHC will contribute 3% of your annual compensation to the plan account each year, with up to an additional 5% match with a 6-year vesting schedule.

• 403(b) retirement savings plan with pre-tax and Roth options. Flexible Spending Accounts for Health Care and Dependent care are also available.

• Onsite Child Care is available in a brand new education facility.
  

• Onsite free gym access. Additional gym, rock climbing wall and salt-water pool available at the Alaska Pacific University for a small fee per semester. Steep discounts on outdoor equipment rentals for your Alaskan adventures!

• Tuition reductions for employees and their eligible dependents at the Alaska Pacific University.

Visit us online at www.anthc.org or contact Recruitment directly at HRRecruiting@anthc.org.

Alaska Native Tribal Health Consortium has a hiring preference for qualified Alaska Native and American Indian applicants pursuant to P.L. 93-638 Indian Self Determination Act.

Summary: Under general supervision, prepare and process eligible beneficiary referrals and claims for services not directly available at ANTHC; reviews and adjusts accounts to ensure accurate and thorough processing of claims.

Responsibilities:

Processes referrals and Medical / Transportation claims for beneficiaries authorized to receive health services from facilities and providers outside of ANMC within an established timeframe.

Determined patient’s eligibility according to established policies and procedures. Reviews claims or bills to determine if referral is on file or if a purchase order needs to be issued. Verifies International Statistical Classification of Diseases (ICD), Current Procedural Terminology (CPT), and revenue codes to determine if diagnosis and treatment were authorized as part of the referral.

Determines payable claims and submits purchase orders. Tracks and monitors claim processing, resolving outstanding claims. Verifies all identified insurance carriers for eligibility; confirms carrier policy. Reviews claims before submission to fiscal intermediary; assesses adjudicated claims. Identifies liability and guarantors; reviews and adjusts account balances; interprets Explanation of Benefits (EOBs); analyzes billing components on claim forms.

Provides assistance to patients, carriers, and other external partners. Answers incoming phone calls and review incoming correspondence and materials, accurately interprets and communicates Medical Claims regulations, policies, and procedures to internal and external customers. Researches unauthorized claims, referral and claim status, and other customer inquiries in a timely, efficient, and appropriate manner to ensure customer satisfaction.

Verify patient and insurance information according to established procedures; obtains alternate health resource information, including Medicaid, Medicare, private insurance, and other liability coverage, prior to authorizing referrals and issuing purchase orders. Provide alternate health resource information, including Medicare, Medicaid, and private insurance, to providers and facilities for patients referred by an ANMC physician. Assist in the decision making process regarding the information.

Research claim status of provider claims with the Fiscal Intermediary. Reviews accounts with credit balances to determine whether an overpayment exists. Participates in payer recoupment, offset, payer refund request and voluntary refund process.

Issues and explains letters of intent or denials (i.e. vacationer/mover, student enrollment,) to customers in a clear and concise manner and according to established standards and procedures under the student and traveler program.

Maintaining strong knowledge of referral and claim processing software, master files and interface conversion tables including data tracking of received medical claims.

Prepares or assist in the preparation of month end reports through desk audit, pending claims reporting from fiscal intermediary, and aging PO’s clean up.

Prioritizing Catastrophic Health Emergency Fund (CHEF) for priority claims processing and reimbursement, verifying medical records, explanation of benefits, alerts, and PO’s, including repricing or negotiating rates of medical claims for savings and discounts through Data Isight and Multi-plan Network.

Attend weekly staff meeting by reporting updates workload and process including any appeals and suggestions of patients and providers issues. Prepare and maintain case files submitted for review and appeals to PRC Director and / or PRC Committee.

Performs other duties as assigned or required.

Other information:

KNOWLEDGE and SKILLS

· Knowledge of electronic medical record systems.

· Knowledge of ICD-10 and CPT coding.

· Knowledge of medical insurance process.

· Knowledge of alternative health resources.

· Knowledge of customer service concepts and practice.

· Knowledge of basic medical terminology and clinic systems.

· Knowledge of the Privacy Act of 1974 and HIPAA Privacy Rule Act of 1966.

· Knowledge of state, federal, and tribal health care programs.

· Knowledge of state, federal and public/private insurance, including Medicaid/Medicare.

· Skill in working independently.

· Skill in grammar, spelling, sentence structure and effective business letter writing.

· Skill in operating office equipment, including copiers and fax machines.

· Skill in interpreting state, federal, and public/private insurance financing.

· Skill in establishing and maintaining cooperative working relationships with others.

· Skill in operating a personal computer utilizing a variety of software applications.

A high school diploma or GED equivalent.

MINIMUM EXPERIENCE QUALIFICATION

Non-supervisory - One (1) year experience in the medical office experience involving medical billing. An equivalent combination of relevant education and/or training may be substituted for experiences.