Medical Claims Specialist II - DOE - (Non-remote)

Join to apply for the Medical Claims Specialist II - DOE role at Alaska Native Tribal Health Consortium (ANTHC) 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. ANTHC offers a competitive and comprehensive Benefits Package for all Benefit Eligible Employees, which includes: Medical Insurance provided through the Federal Employee Health Benefits Program as a Tribal Employee, with over 20 plans and tiers. Cost-Share Dental and Vision Insurances Discounted Pet Insurance Retirement Contributions with Pre-Tax or Roth options into a 403(b). 401(a) ANTHC Retirement Plan: After one year of employment, ANTHC will begin making matching contributions of up to 5% of your eligible pay, based on your own contributions. In addition, you may be eligible for an annual discretionary contribution of up to 3% from the employer. Paid Time Off starts immediately, earning up to 6 hours per pay period, with paid time off accruals increasing based on years of service. Eleven Paid Holidays Paid Parental Leave or miscarriage/stillbirth eligibility after six months of employment Basic Short/Long Term Disability premiums, Accidental Death and Dismemberment (AD&D) Insurance, and Basic Life Insurance are covered 100% by ANTHC, with additional options for Short-Term Disability Buy-Up Coverage and Voluntary Life for yourself and your family members. Flexible Spending Accounts for Healthcare and Dependent Care. Ancillary Cash Benefits for accident, hospital indemnity, and critical illness. On-Site Child Care Facility with expert-designed classrooms for early child development and preschool. Employee Assistance Program with support for grief, financial counseling, mental/emotional health, and discounted legal advice. Tuition Discounts for you and your eligible dependents at Alaska Pacific University. On-Site Training Courses and Professional Development Opportunities. License and certification reimbursements and occupational insurance for medical staff. Gym Access to Alaska Pacific University includes a salt water pool, rock climbing, workout gym, and steep discounts for outdoor equipment rentals. Emergency Travel Assistance Education Assistance or Education leave eligibility Discount program for travel, gym memberships, amusement parks, and more. 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. Other Information Performs other duties as assigned or required. 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.

MINIMUM EDUCATION QUALIFICATION

A billing or coding certification and/or Associate’s degree in medical billing and coding, Business, Finance, Accounting, or related field. Progressively responsible accounting technician, medical billing, or related work experience may be substituted on a year-for-year basis for college education. Minimum Experience Qualification Non-supervisory - Two (2) years of accounting, medical billing, insurance, medical claims care office or related experience. An equivalent combination of relevant education and/or training may be substituted for experience. 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. #J-18808-Ljbffr Alaska Native Tribal Health Consortium (ANTHC)