Health Care Payment Specialist

Salary Pay Range:

$27.05/hr.-$34.95/hr.

Essential Functions:

Communicates with other employees/customers through written, oral and face-to-face interactions. Participates in discussions about confidential/sensitive matters, maintains confidentiality of patients at all times. Coordinates benefits with providers through means of patient referrals, discussing individual cases to ensure continuity and follow up of care. Provides assistance with Medicaid application process and refers patients to alternate resources. Coordinates benefits and assists tribal members with alternate resources available. Loads, verifies accuracy and processes all claims for Tribal member health program, manually and via an imported file from the Third-Party Administrator (TPA). Coordinates & Communicates claims issues with TPA ensuring proper use of all network discounts and alternate resources available. Determines level of patient care to ensure services are within payment guidelines. Ensures the integrity of data entered for PRC and tribal member health program check processing; pre-report, document control register, vendor payment, vendor claim report, object class code report, check run, alternate resource use and checks printed report. Prints checks twice per week via Plexis LCS for all eligible PRC and Tribal Health Program. Mails Vendor Payment document and Vendor Denial Correspondence Issues all payment denials for PRC and tribal member health program Exports TPA PRC check file via Plexis LCS to FileZilla. Ensures proper internal control and security of PRC and Tribal Trust Fund checks. Performs administrative duties assigned to the PRC function such as: Tribal Trust Fund (TTF) deferred services reports, ensures weekly spending rate is maintained, maintains and completes catastrophic cases to ensure reimbursement, maintains records and files as required, and prepares statistical PRC program reports as requested. Tracks and generates patient warning letters for patients not in compliance with PRC and tribal member health program guidelines. Documents PRC refunds in a timely manner. Maintains Tribal Trust Fund (TTF) deferred services log. Administers Tribal Trust Fund money for deferred services and direct care patients as directed. Performs a variety of other duties as assigned by supervisor.

Education, Experience, and Licenses:

Requires a high school diploma or GED and a minimum of six (6) months of post high school specialized job skills training in the medical secretarial or Purchased/Referred Care (PRC) (formerly CHS)/medical insurance billing. Courses in office machines, personal computer programs, medical terminology, ICD-9 & 10 coding, ten key, and bookkeeping are examples of course work completed as preparation for this position. Requires a minimum of three (3) years of work experience in accounting clerk, secretarial or administrative assistant position working in medical clinics or the PRC (formerly CHS)/medical insurance billing field. OR equivalent combination of education, training and experience.

Driving Requirements:

Employees may be required to drive for work-related purposes and must maintain a valid Oregon Driver's License (ODL), meet company vehicle insurance requirements, and provide proof of personal vehicle insurance.

Qualifications, Registrations, and Certifications:

Requires considerable tact with daily patient contact; approving or denying authorization of payment for medical services, encouraging patients to apply for alternate resources, gathering information regarding patient insurance, and giving information on PRC system, eligibility and process. Requires knowledge of medical terminology and

ICD-9 & 10

coding. Knowledge of Plexis LCS computer system preferred. Knowledge of and sensitivity to Native American culture required.

Environmental Factors and Conditions/Physical Requirements:

Continually requires the ability to express or receive detailed information or important instructions through oral communication. Continually requires working with fingers rather than the whole hand or arm. Requires repetitive movement of wrists, hands and/or fingers. Often requires walking or moving about to accomplish tasks. Requires standing and/or sitting for sustained periods of time, raising objects from a lower to a higher position and/or moving objects horizontally. Occasionally requires lifting of up to 40 pounds. This position is frequently subject to inside environmental conditions which provide protection from weather conditions, but not necessarily from temperature changes, and is occasionally subject to outside environmental conditions. Supports a safe work environment by performing all duties in accordance with Tribal safety policies and procedures, and Emergency Management Plan. Due to the nature of the interactions with other employees and the public we serve, employees may be required to provide documentation of, or receive, certain health vaccinations. May be called upon to serve as a Disaster Reservist during emergencies. Local travel is occasionally required. Travel outside of the state is infrequently required.

Background Check:

Candidates for this position will be subject to criminal and character background checks and may be subject to fingerprinting.