Under general supervision, ensures that all Indian Health contract Health Service requirements are met for all eligible clients/patients; and assists in all necessary daily operations of the CHS program. Will administer contracted health care to eligible clients according to the federal rules/regulations, and based on annual fixed funding base. Incumbent is responsible for assuming dual responsibility for processing routine and complex health claims as well as providing customer service for assigned accounts and for assuming primary responsibility for processing routine complex health claims on multiple assigned accounts. Acts as a resource for client’s/community members and other health care division staff.

1. Ensures that all IHS eligibility criteria requirements are met prior to clients receiving services.
2. Follows rules, guidelines and procedures in solving problems. Practices ability to find practical ways of dealing with problems and situations. Works as a team member, staying pleasant and even-tempered in dealing with customers.
3. Performs repetitive tasks with out becoming careless or compromising efficiency. Will work accurately and expediently under time constraints, pressure and emotional strain. Incumbent will be expected to memorize and retain information utilizing long and short term memory capabilities.
4. Ensures that all other alternate services have been exhausted for client, remaining knowledgeable of all other resources and giving accurate/correct instruction on how the client is to obtain resources available to them.
5. Exercises and maintains high level of confidentiality. Ability to handle difficult situations, under emergency conditions in a calm and professional manner.
6. Determine level of medical services requested within IHS/Tribal priorities. Ability to inform client in a professional manner, of services that will not be covered.
7. Assist other CHS staff with claims as needed to minimize backlog.
8. Perform routine and complex administrative and clerical tasks to remain current on procedures and medical claims processing resources, and to update CHS RPMS claims systems data.
9. Maintain current knowledge of all alternated resources available to clients and effectively apply this knowledge to all job functions.
10. Conduct in-depth research to resolve medical claims issues and compose detailed and customized correspondence as necessary.
11. Assist patients and other health program staff with questions pertaining to processing of medical claims, direct questions and problems as necessary.
12. Independently process routine medical and complex health claims of all types in accordance with all private, state, federal plans with primary client service responsibility.
13. Maintain the privacy and confidentiality of all protected health information in accordance with the Division’s Policies and Procedures, and in compliance with state and federal regulations.

Graduation from high school or equivalent,  three (3) years experience processing all types of health/dental claims, two (2) years in depth knowledge of all aspects of benefits claims processing and two (2) years customer service background.

Knowledge of: All other private insurance plans and how they are to be utilized by clients; such as private insurance based preferred (PPO) plans, HMO’s, all state Medicaid programs available to clients and Medicare Part A &B Crippled Children, Basic Health. Knowledge and experience with basis alpha filing. Knowledge of all aspects of benefits claims processing, claims principles and procedures, medical and/or dental terminology and procedures, and ICD9 and CPT codes. Knowledge of health, social services and resources.

Skilled in and Abilities: Ability to be dependable and prompt. Ability to type 30-40 WPM. Ability to read and interpret documents such as procedure manual and health care plans. Oral communication skills, ability to speak effectively and present information in a one-on-one as well as small group situations to customers, clients and other employees of the Health program. Ability to calculate figures and amounts such as discounts, proportions and percentages. Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule forms. Ability to meet production and quality goals on a consistent basis. Record-keeping. Working with diverse populations. Performing a number of tasks simultaneously. Working as a part of a multidisciplinary team. Meeting deadlines and working under time constraints.

The working conditions described here are representative of those that must be met by an employee to successfully perform the essential duties of this class. While performing the duties of this job, the employee is frequently required to sit and talk or hear. The employee is occasionally required to walk; use hands to operate, finger, handle, or feel objects, tools, or controls; push and pull; and reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.  The noise level in the work environment is usually moderately quiet.