Health Claims Auditor I Non-Certified bei Cherokee Nation

Verifies claims eligibility, reviews claims for accuracy and appropriateness of billing, coordinates third party benefits, prepares check requests, picks up and disburse checks, maintains records, tracks and prepares high cost cases for IHS reimbursement.  Other duties as assigned.

Routine duties shall include providing audit services related to health care services to individuals eligible for services in accordance with the self-governance compact and funding agreement between the Cherokee Nation and the United States executed under the authority of the Indian Self-Determination and Education Assistance Act. Investigates and verifies participation, eligibility, level, and type of benefit by telephone and/or written notice. Reviews claims to determine authorized coverage,appropriate coding, modifiers, and charges per contractual agreement, and/or appropriate Diagnostic Related Group. Coordinates third party benefits. Processes a variety of claims for payments by using the proper standards. Maintains records of claims in the Contract Health Services system. Prepares and submits check requests to Finance using relevant accounting coding. Picks up and disburses check to  Contract Health Services vendors. Receives and processes refund checks from vendors. Answers questions on status of payments, eligibility, and processes for patients and vendors. Maintains information in the electronic health record. Composes reports and correspondence. Maintains eligibility logs and files. Tracks participant eligibility and payments. Generates related reports. Tracks and prepares Catastrophic Health Emergency Fund documents for submission to Indian Health Services for reimbursement. Other duties may be assigned.

SUPERVISORY RESPONSIBILITIES                                                   

This job has no supervisory responsibilities.

EDUCATION REQUIREMENT                                                    

High school diploma or general education degree (GED).

EXPERIENCE REQUIREMENT

At least two years experience in a related field.

COMPUTER SKILLS                                            

An individual should have knowledge of Accounting software; Database software; Internet software; Spreadsheet software and Word Processing software.

CERTIFICATES, LICENSES, REGISTRATIONS

Must possess a valid driver's license with a driving history verified through a motor vehicle report that meets the requirements for Cherokee Nation underwriting.  Driving is necessary to attend trainings, pick up and disburse checks.

OTHER SKILLS AND ABILITIES                                   

None

OTHER QUALIFICATIONS

Employee must not and will not be under sanction by the United States Department of Health and Human Services Office of the Inspector General (OIG) or by the General Services Administration (GSA) or listed on the OIG’s Cumulative Sanction Report, or the GSA’s List of Excluded Providers, or listed on the OIG’s List of Excluded Individuals/Entities (LEIE).

PHYSICAL DEMANDS

While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is frequently required to reach with hands and arms. The employee is occasionally required to stand; walk; climb or balance and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds.

WORK ENVIRONMENT

The noise level in the work environment is usually moderate.