Claims Processing Specialist (TM46676)

Closing Date: April 10, 2026

Position: Claims Processing Specialist/PRC

Salary: $22.20 - $27.03

Reports to: PRC Program Administrator

Location: Nespelem

SUMMARY:

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. This position is distinguished by its specialized knowledge of PRC funding regulations, claims adjudication, and coordination of benefits in the context of Indian Health Service delivery. The role requires a high degree of accuracy, confidentiality, and attention to detail, as well as the ability to work independently and in collaboration with other health service and administrative staff. Familiarity with third-party payers, denial management, and medical coding is essential.

ESSENTIAL FUNCTIONS:

• Receives, reviews, and processes PRC claims in accordance with applicable tribal, federal, and IHS PRC regulations.
• Verifies patient eligibility and prior authorization status for each claim.
• Reviews documentation for completeness, accuracy, and compliance with medical necessity guidelines and program policy.
• Determines appropriate payment or denial of claims and documents the rationale for decisions.
• Enters claims into the Electronic Health Record (EHR) and/or PRC-specific tracking systems (e.g., RPMS, NextGen).
• Ensures timely processing within designated timelines to avoid late payment penalties or audit flags.
• Coordinates with external providers and internal staff to resolve billing discrepancies or claim denials.
• Prepares Explanation of Benefits (EOBs) and communicates determinations with providers and/or patients.
• Supports audits by maintaining detailed and organized claim records.
• Participates in training, policy updates, and compliance reviews related to PRC processes.
• Assists in reconciliation of PRC financial reports and supports annual reporting requirements. Ensure confidential handling of sensitive team member information in line with data protection policies
• Performs other duties as assigned

KNOWLEDGE, SKILLS, AND ABILITIES:

• High School Diploma or GED required.
• 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.
• Must pass a criminal background check.
• Working knowledge of PRC program regulations and federal IHS policies.
• Proficiency in medical claims processing, including knowledge of CPT, ICD-10, and HCPCS

coding systems.

• Knowledge of insurance reimbursement systems and coordination of benefits.
• Familiarity with tribal health programs and funding streams is preferred.
• Strong analytical and decision-making skills.
• Proficient in data entry and electronic health records systems.
• Ability to interpret policies, procedures, and medical documents accurately.

Effective written and verbal communication skills.

• Ability to maintain confidentiality and comply with HIPAA regulations.
• Ability to work under pressure and meet strict deadlines.
• Ability to resolve billing discrepancies diplomatically and effectively.
• Ability to work independently and collaboratively with clinical and administrative teams.
• Ability to prioritize work, multitask, and adapt to changing program requirements.

Ability to explain program eligibility, denials, and payment policies to patients and providers.

PHYSICAL REQUIREMENTS:

• Primarily office-based within a tribal health care setting.
• May involve working with sensitive patient data and confidential claims information.
• Exposure to interactions with patients and providers regarding claim status, which may involve conflict resolution.
• Requires adherence to strict confidentiality standards and regulatory guidelines.
• Ability to sit and stand for long periods of time
• Manual and finger dexterity to complete duties
• Ability to frequently bend, stoop, and reach
• Ability to push and pull frequently
• Ability to comprehend complex issues
• Sufficient visual acuity to write, recognize printed materials, computer screen, and notice non-verbal behavior
• Speech and hearing ability to project voice to small and large audiences, carry on telephone conversations, hear and grasp verbal communications and equipment prompts
• Ability to drive in adverse weather conditions

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: Terri Mail, HR Generalist, Colville Tribal Health Care Authority, Human Resources Office, P.O. Box 150, Nespelem, WA 99155, (509) 846.3774. terri.mail.ohc@colvilletribes.com