Description
Open To All Applicants
Salary is Negotiable
After successful completion of the probationary period, employee will receive off probation wage increase.
Summary:
This position will assist in the management of the referral system for authorized indirect health services to include interviewing patients, identification and coordination of alternate resources of payment, entering referral data to computer system, adjudication of claims received, re-pricing claims with Medicare-like rates, application for catastrophic health emergency funds(CHEF) reimbursement, processing approved charges to supervisor for payment and approval, and general clerical duties.
Responsibilities:
* Review and determine patient's Purchased Referred Care (PRC) eligibility based on PRC and Indian Health Service (IHS) guidelines:
a. Request updates from patients on address, phone numbers, insurance information, tribal IDs and proof of residency
b. Interviewing patients to determine recipients' eligibility for alternate resources. Refer to Medical Benefits Coordinators as needed/required as they are the experts in alternative resources.
c. Process applications as needed and update PRC eligibility, demographic and insurance information in PRC and Electronic Medical Record (EMR) systems.
d. Notify patient of any missing information and PRC eligibility changes
* Review and process referrals from Oneida providers to outside providers:
a. All referrals are reviewed for errors: priority level, diagnosis codes, services ordered, number of visits and type of referral.
b. Ensure services/treatment ordered is covered via PRC and IHS guidelines.
c. Review patient's PRC eligibility to ensure they are still up to date.
d. Review if outside provider is in network with the patient's insurance (if applicable).
e. Review referrals with patients in detail f. Document patient's chart with applicable referral information
* Processing of Emergency Room (ER)/Urgent Care Visits:
a. Reviewing patient's PRC eligibility, insurance status and tribal status
b. Creating PRC referral for eligible ER/Urgent Care visits in PRC system and sending for review
c. Sending note to inform patients primary care provider of the visit for review
* Payment of claims/statements:
a. Determine if claims received are in appropriate format and if insurance remittance is included (if applicable) or if the claim & remittance still needs to be requested from outside provider and sending those requests.
b. Review if claim received is for an approved referral for treatments received with that provider, within the authorization dates of the referral and within the allotted number of visits.
c. Request additional information from outside providers as needed.
d. Review of insurance remittances for denial codes to ensure additional information is not needed from the patient.
e. Pay approved claims or send denials to patient and outside provider. f. Processing of claims that are overturned on appeal
* Reviewing and processing reports from PRC System Coordinator, PRC Supervisor and outside providers on claim/payment status, pended claims, pending eligibility and other issues that are not resolved
* Logging into department phone tree to take calls from patients, outside providers and other internal/external customers
a. Provide information for PRC eligibility requirements, status of payment and other general questions.
b. Assist patients with referral requests by entering chart for provider review
* Meet with patients that walk-in to address questions and/or concerns they have regarding PRC related matters
* Establish and maintain an effective filing and retrieval system to assure allowable claims are paid timely to avoid any negative situations for Oneida or patient
* Assist in processing refunds from outside providers to include identifying referral affected, entering payment adjustment in PRC system
* Assist with clerical duties:
a. Open, date stamp and sort incoming department mail
b. Draft correspondence to patients for necessary updates and other information
c. Send copies of referral to patients with applicable cover letters
* Re-price Medicare-Like Claims for payment processing in accordance with Federal Register.
* Assure all HIPAA requirements are adhered to in all Purchased/Referred Care related matters.
* Attend State and Regional Purchased/Referred Care meetings to keep abreast of current guidelines and regulations.
* Contributes to a team effort and accomplishes related results as required
Skills:
Essential:
* Business English, proper spelling, grammar, punctuation, and basic arithmetic
* Inform and communicate verbally and in writing in diverse and challenging situations with the ability to process information effectively, identify and define problems and make objective decisions
* Preparing and maintaining patient records
* Knowledge of applicable Oneida Nation, federal, state, county and local laws, regulations, and requirements
* Knowledge or training in basic Accounting procedures
* Knowledge of the nature and provisions of alternative health insurance plans
* Knowledge of ICD-10, HCPC and/or CPT medical billing codes
* Knowledge of Indian Health Services (IHS) rules and regulations pertaining to eligibility
* Must have the ability to work independently with minimal supervision and also as a team to address complex problems and meet strict deadlines
* Knowledge of medical billing procedures
* Knowledge of medical insurance claims procedures and documentation
* Knowledge of the precertification requirements, procedures and documentation of third-party medical insurance payors
* Knowledge of Medicaid, Medicare, Social Security, Tribal and County Department of Human Services and private health insurances is required
* Knowledge with records management procedures
* Ability to establish and maintain professional relationships with individuals of varying social and cultural backgrounds and with co-workers at all levels.
* Must comply with Caregiver Law and Grant conditions criminal history checks as a condition of employment to include fingerprinting
* Ability to represent the organization in a professional manner, building respect and confidence.
* Operating business computers and office machines, including word-processing, spreadsheets, database software programs, POS system and e-mail
* Ability to gather data, compile information, and prepare reports
* Ability to handle multiple tasks and meet deadlines
* Ability to analyze and solve problems
* Knowledge of or willingness to learn the social and economic conditions in the local community and availability of resources to which a client may be referred
Education Requirement - Or A Closely Related Field:
Education with Equivalent Qualifications:
Essential:
* Applicants age 50 and older are exempt from this requirement
* General Ed, High School Equivalency Diploma, HS Diploma
Credentials:
Nonessential:
* Child Abuse Reporting Policy (CARP) (Hrd), obtain within ninety (90) days of employment
* Health Insurance Portability (HIPAA) Accountability, complete within thirty (30) days of employment and annually thereafter
Working conditions:
Essential:
* Stand frequently
* Reach frequently
* Talk frequently
* Sit occasionally
* Bend/stoop occasionally
* Kneel occasionally
* Move 11-24 pounds occasionally
* Evening and weekend work may be required
* Office setting
* Work extended hours
* Work irregular shifts
* Covid vaccination required
* Flu vaccination required
* Measles mumps rubella vaccination required
* Varicella vaccine required
Experience:
Essential:
* Medical office experience
* Third-party billing and knowledge of Medicaid, Medicare, and
Other information:
EQUAL EMPLOYMENT OPPORTUNITY STATEMENT - The Oneida Nation does not discriminate based on race, color, national origin, sex, religion, age or disability status in employment or the provision of services. However, individuals of Indian ancestry and Veterans will be given preference by law in employment.
Continuation of this position is contingent upon funding allocations.
Must maintain strict security, confidentiality, and quality to meet professional standards of the department.
Must adhere to all Oneida Nation Personnel Policies and Procedures, Oneida Nation Standard Operating Procedures, and Area and Program Strategic Plans and Policies.
Must pass a background check to meet Employment Eligibility Requirements. If applicable, must pass a background check to meet Oneida Nation/State Compact and/or Oneida Nation Gaming Ordinance, and may be required to obtain a temporary license and/or Gaming license as a condition of employment.
Must be willing and able to obtain additional related education and training.
Must pass a pre-employment drug screen and adhere to the Nation Drug and Alcohol-Free Workplace Policy.
A Tuberculosis (TB) Screening and/or a 2 step TB Skin Test is required within thirty (30) days of employment.
Must provide a copy of diploma/degree, license, or certification upon employment.
ITEMS TO BE SUBMITTED:
1. Must provide a copy of diploma, license, degree, or certification upon employment.
2. Must have received or be willing to receive the COVID-19 vaccination by date of hire to be considered. Proof of vaccination required.
4. Employees are required to have proof of seasonal influenza vaccination; medical or religious exemption may be requested upon hire.
5. Background information disclosure (BID)
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