Here’s what you’ll be doing:
| Level II | Level III |
1 | Analyzes and processes minimum of 200 claims daily to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims | Analyzes and processes minimum of 400 claims to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims |
2 | Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations | Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations |
3 | Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments | Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments |
4 | Assists with other research and development projects as directed by Management; obtains and maintains necessary certification for Health Insurance Marketplace CAC | Provides training and guidance through expert knowledge of claims administration and adjudication to Insurance Department staff; responsible for the timely response to formal appeals from members, employees, clients and providers |
5 | Reviews, resolves and/or escalates Level 2 claims appeals; releases claims up to the designated draft authority for Level 2 Claims Examiner | Works with the Customer Service Coordinator to manage and provide direction to the utilization review and case management vendor; identifies and manages claims with potential subrogated recovery |
6 | Ensures that claims adjudication complies with all FCPID standards and protocols; reviews claims for possible abuses and/or fraud and bring to the attention of management | Oversees the repricing processes to ensure the integrity of the product; investigates claims referred by staff for possible abuse and fraud |
What you’ll need to be successful:
| Level II | Level III |
1 | High School Diploma or GED | High School Diploma or GED |
2 | Five (5) years of experience in medical claims processing | Five (5) years of experience in medical claims processing |
3 | Three (3) years in customer service | Three (3) years in customer service |
4 | Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards | Two (2) years in a lead or supervisory capacity |
5 | Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology | Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards |
6 | Knowledge of insurance principles and/or procedures | Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology |
7 | Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment | Knowledge of insurance principles and/or procedures |
8
| Must successfully pass all applicable background checks and drug screens
| Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment |
9 |
| Must successfully pass all applicable background checks and drug screens
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Benefits you’ll love: