Claims Technician - Temporary position

Position Summary:

The Claims Technician will receive and process Air, Ambulance and Medical claims for medically necessary services to qualified individuals in the managed health care plan administered by the Navajo Health Foundation/Sage Memorial Hospital (NHF/SMH). This position provides support services to the Purchased Referred Care Department in maintaining a viable program that demonstrates compliance with policy and regulations.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Develop and maintain a working knowledge of Arizona Health Care Cost Containment System (AHCCCS) rules and regulations and the terms and conditions of all NHF/SMH Managed Care contracts.
• Determine third party payer resources and eligibility of individuals for NHF/SMH managed care program using all sources of information available, including the NHF/SMH computer system.
• Complete, maintain, compile, and report accurate manual and electronic documentation of all job-related activities in NAIHS system and spreadsheets.
• Participate in and attend all required in-services and educational programs to improve and/or learn job-related skills.
• Uphold all principles of confidentiality and patient care according to NHF/SMH policy and procedures.
• Maintain communications with IHS and non-IHS facilities regarding patient referrals.
• Maintain PRC files according to established filing system.
• Receive patient/vendor notifications for medical services.
• Participate in and contribute to NHF/SMH and departmental quality improvement initiatives.
• Gather information on sensitive PRC cases for eligibility, denials, appeals and submit to immediate supervisor for review/approval.
• Provide administrative support to the immediate supervisor.
• Perform other duties as required.

Ambulance transports:

• Receives notifications for ambulance services for patients that are utilizing their services.
• Verify patients are in SMH PRC service area.
• Verify insurance information. If patients do not have alternate resources such as Arizona Medicaid, Medicare, private insurance, request for required documents (Proof of Residency, Alternate Resources and Certificate of Indian Blood). send letters out to patients and to vendors. Record information into proper spreadsheets. Send correspondence to patients and vendors and update information in proper spreadsheets.
• Scan documents in patient’s EHR

Transfers:

• Receive notifications for patients who are transferred out from SMH ED or other IHS facilities,
• Verify patient is in SMH service (same as above, record information into proper spreadsheets).

Medical/AMB/Flight claims:

• Verify patient is in our service area.
• Verify patient has insurance-Medicare, AHCCCS, private insurance.
• Verify patient has a Sage Hospital or IHS referral/notification on file.
• Verify patient meets PRC eligibility requirements.
• Verify vendor has documentation on file (W9) in our vendor listing.
• Verify claim as explanation of benefits (EOB) attached to the claim.
• If a patient has Medicare, SMH PRC will pay Medicare Coinsurance or deductible.
• Patients who do not have any insurance, NAIHS, HCPC codes are looked up utilizing the CMS website. Calculations are made according to the CMS website (utilizing the Wage Index/MLR for the UB04-0131-outpatient claims, Web Pricer/DRG for inpatient stays).
• Post payments into Meditech Expanse.
• Copies are taken to Finance for payment to be issued.

Knowledge, Abilities, Skills, and Certifications:

• Excellent customer relations and telephone skills is a necessity.
• Ability to work in a high stress environment performing tasks requiring attention to detail and precision.
• Ability to work independently and follow tasks given by supervisor.

Physical Demands:

While performing the duties of this job, the employee regularly is required to sit long periods of time. The employee frequently is required to walk, stand, bend, stoop. The employee may occasionally lift and/or carry items weighing up to 25 pounds.

Work Environment:

Work is generally performed in an office with moderate noise level. Extended hours and irregular shifts may be required.