Claims Processing Specialist - (TI-43684)

CLOSING DATE:       Open Until filled, with bi-weekly reviews

POSITION:                  Claims Processing Specialist (3 positions)

SALARY:                    $21.82 to $23.15 per hour DOE

REPORTS TO:           Program Supervisor

LOCATION:                Nepelem for 6 month Training, Purchased/Referred Care, Nespelem, WA - posible opprotunity to work in other Tribal Districts after training completed

Basic Functions:      This is a Non-Exempt position. The Claims Processing Specialist is responsible for the accurate and timely processing of claims submitted to the Purchased/Referred Care (PRC) program. This role involves verifying patient eligibility, ensuring compliance with federal PRC regulations, coordinating with providers and vendors, and maintaining detailed records of claims for audit and reporting purposes. The position requires a working knowledge of medical billing codes, insurance reimbursement processes, and the PRC program guidelines governed by the Indian Health Service and tribal policies.

MINIMUM QUALIFICATIONS:

Education and Training: 

• Associate’s degree in health administration, business, or a related field preferred.
• Minimum of two (2) years’ experience in medical billing, claims processing, or PRC services.
• Experience working with tribal health programs or IHS preferred.
• Certification in medical billing or coding preferred (e.g., CPC, CPB, CBCS).
• Must possess a valid Washington State driver’s license and be insurable under the Tribe’s vehicle insurance policy.

Knowledge, Skills, and Abilities:

• Requires a Working knowledge of PRC program regulations and federal IHS policies.
• Requires proficiency in medical claims processing, including knowledge of CPT, ICD-10, and HCPCS coding systems.
• Requires knowledge of insurance reimbursement systems and coordination of benefits.
• Requires familiarity with tribal health programs and funding streams is preferred.
• Requires strong analytical and decision-making skills.
• Requires proficient in data entry and electronic health records systems.
• Requires effective written and verbal communication skills.
• Requires ability to maintain confidentiality and comply with HIPAA regulations.
• Requires ability to work under pressure and meet strict deadlines.
• Requires ability to resolve billing discrepancies diplomatically and effectively.
• Requires ability to work independently and collaboratively with clinical and administrative teams.
• Requires ability to prioritize work, multitask, and adapt to changing program requirements.
• Requires ability to explain program eligibility, denials, and payment policies to patients and providers.
• Requires ability to interpret policies, procedures, and medical documents accurately
• Must be able to sit and work at a computer station for extended periods.
• Requires physical ability such as occasional lifting of files, records, or office supplies up to 25 pounds.
• Requires hearing and speaking to exchange information and read documents.
• Requires ability to travel occasionally for training or program coordination.

Note: Pursuant to Tribal Policy, if this position is safety sensitive it is subject to pre-employment drug testing. In addition, this position is subject to reasonable suspicion and post-accident drug testing.

TRIBAL MEMBER AND INDIAN PREFERENCE WILL APPLY; PREFERENCE WILL ALSO BE GIVEN TO HONORABLY DISCHARGED VETERANS WHO ARE MINIMALLY QUALIFIED.

If required of this position, you must possess and maintain a valid Washington State driver’s license and be eligible for the Tribes’ Vehicle Insurance.  In addition, this position may be subject to pre-employment background clearances.  If applicable, these clearances must be maintained throughout employment.

INFORMATION: Tanya Ives, HR Technician Senior, Confederated Tribes of the Colville Reservation, Human Resources Office, P.O. Box 150, Nespelem, WA 99155, (509) 634-2201. tanya.ives.hrs@colvilletribes.com