Here’s what you’ll be doing:
Level II
Level III
1
Analyzes and processes minimum of 200 claims daily to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims
Analyzes and processes minimum of 400 claims to determine plan liability; reviews payment Purchased Referred Care, medical, dental and vision claims
2
Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations
Compiles, submits documents, and tracks claims for CHEF, (Catastrophic Health Emergency Fund), for reimbursement, to Bemidji Area Contract Health for high-cost cases, following current IHS guidelines and regulations
3
Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments
Collaborates with the Eligibility team to ensure payer of last resort stance is utilized when handling Purchased Referred Care claims and payments
4
Assists with other research and development projects as directed by Management; obtains and maintains necessary certification for Health Insurance Marketplace CAC
Provides training and guidance through expert knowledge of claims administration and adjudication to Insurance Department staff; responsible for the timely response to formal appeals from members, employees, clients and providers
5
Reviews, resolves and/or escalates Level 2 claims appeals; releases claims up to the designated draft authority for Level 2 Claims Examiner
Works with the Customer Service Coordinator to manage and provide direction to the utilization review and case management vendor; identifies and manages claims with potential subrogated recovery
6
Ensures that claims adjudication complies with all FCPID standards and protocols; reviews claims for possible abuses and/or fraud and bring to the attention of management
Oversees the repricing processes to ensure the integrity of the product; investigates claims referred by staff for possible abuse and fraud
What you’ll need to be successful
Level II
Level III
1
High School Diploma or GED
High School Diploma or GED
2
Five (5) years of experience in medical claims processing
Five (5) years of experience in medical claims processing
3
Three (3) years in customer service
Three (3) years in customer service
4
Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards
Two (2) years in a lead or supervisory capacity
5
Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology
Knowledge of Indian Health Service guidelines as it pertains to payment of medical providers and health benefits claims processing standards
6
Knowledge of insurance principles and/or procedures
Knowledge of NCCI and CMS coding/billing standards, CPT-4, ICD-9, ICD-10, DRG and HCPS and medical terminology
7
Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment
Knowledge of insurance principles and/or procedures
8
Must successfully pass all applicable background checks and drug screens
Skill in operating various word-processing, spreadsheets, and database software programs in a Windows environment
9
Must successfully pass all applicable background checks and drug screens
Benefits you’ll love:
The Forest County Potawatomi Community (FCPC) is a Native Sovereign Nation located in Crandon, Wis., with operations based in Crandon and Milwaukee. FCPC is the largest employer in Forest County and offers employment and career opportunities in a wide and varied field of sectors that include: Healthcare, Education, Social Services, IT, Finance, Human Resources, Legal, and Administrative Support Services.
While FCPC provides its employees family-sustaining wages and above average benefit packages, an added plus is the rich and colorful Native American culture that’s naturally woven into the fabric that makes this community so special.
Although we cannot say this about the fine, big city of Milwaukee, life in Forest County (and the Northwoods as a whole) is a bit slower, with a simpler approach to living the dream. That’s because we live IN the dream. This is rural at its best: rivers, lakes, fresh air, wildlife, forests, and four full seasons – not to mention the fun activities that pair so well with all those things! We work hard; we play hard.
It should also be noted that some young people graduate high school and leave the Forest County nest, and for many reasons: college, career, adventure. Yet, many of them return when they begin a family. The reason is simple: This is a great place to raise kids. This is a small community with a big heart and down-to-earth values.
It must be said that the arrival of Indian Gaming and forward thinking were the main catalysts in creating those ‘family-sustaining wages and above average benefit packages’ that now exist and that allow young people to return. This was not always the case.
Having said all that, there’s just one question to ask: What are you waiting for? Take a breath of fresh air, dip your toes in the water, grab a sled and head for the hill, or take in the scenery on foot, on skis, in the car. If FCPC can provide the job, you can provide the fun!
Now is the time to take the next step toward your future.
