Position Summary: Performs a variety of activities to process claims associated with private referrals to ensure compliance with established contracted health program requirements and Tribal standards. Enters claims data, reviews benefit eligibility, and processes approvals and denials for customers.

Critical Tasks: 

Adjudicates health insurance claims for payment through contract health program by verifying beneficiary eligibility and identification of alternative funding sources.Knowledge of health care industry and/or claims processing as generally gained through 1-2 years of experiencePossess knowledge of medical claim forms for institutional/facility claims (UB04) and professional claims (CMS 1500)Knowledge of pricing methodologies including ASC, APC/OPPS, DRG, Medicare pricers and Medicare Like RatesAbility to read and understand complex provider contracts and apply appropriate payment methodologies to claimsPrepares reports of claims processed in accordance with contract.Initiates requests for appropriate documents and records needed to facilitate adjudication of claim.Begins requests for purchase order for payments of authorized claims through contract health; issues EOB statements and forward to recipient.Updates all claim files and records. Analyzes and identifies trends and provides reports as necessary.Processes emergency treatment notification and verifies compliance with contract terms and conditions.Performs other job-related activities as requested.

Required Qualifications: 

High School Diploma or GED required.6 months of experience in medical claims preferred. Demonstrates ability to relate to diverse cultures and specifically the Gila River Community and/or other Native American cultures and community health services.