Purchased Referred Care (PRC) Coordinator

Job Summary: This position is responsible for initiating, tracking, and processing “payer of last resort” health insurance claims according to United Indian Health Services (UIHS) Contract Health Services (CHS) guidelines.
It requires a thorough knowledge of: Purchased Referred Care services and alternate resources, that may include but is not limited to private insurance, and Medicare/Medicaid programs; knowledge of alternate resources including the Affordable Care Act (ACA); knowledge of funds control techniques to account for the funds allotted for the Purchased/Referred Care services; and knowledge of specialized medical terminology that may include diagnosis and procedural terms.
Essential Functions: Maintains Contract Health Service files.
Determines if incoming Contract Health Services referrals are within the UIHS approved priorities.
Prepare and follow up on Contract Health Services referrals that need medical and dental review.
Determines if clients meet eligibility requirements, including referral to Alternate Resources for screening and application if eligible.
Contact outside providers to set up appointments for approved cases, ask for an estimate of charges, and notify clients of scheduled appointments.
Create purchase orders for eligible approved referrals.
Communicates and corresponds with outside agencies and clients regarding claim submission.
Communicates and corresponds with clients/providers regarding status of Contract Health Services claims.
Communicates and corresponds with UIHS providers to clarify Contract Health Services referrals and address case status questions.
Tracks Contract Health Services cases through the processes of appointment, procedural scheduling, outcome, third party insurance eligibility determination, and final claims payment processing.
Tracks and submits claim reimbursements through Contract Health Services.
Prepare and submit Catastrophic Health Emergency Fund (CHEF) cases following guidelines from IHS.
Notify supervisor of possible pending CHEF cases so they can be reported to the Patient Registration/ Contract Health Services committee.
Responds to inquiries and requests for PRC services assistance via telephone, written communication, or personal visit.
Coordinates these requests and provides consultation to resolve problems or issues.
These requests in many instances originate from a variety of sources requiring contact with outside agencies and organizations.
Must comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPAA).
Performs related duties.
Professional Behavior Effectively plan, organize workload, and schedule time to meet the demands of the position.
Work in a cooperative and professional manner with OHC and GPTLHB staff.
Treat Great Plains tribes and collaborators with dignity and respect.
Utilize effective verbal and written communication skills.
Advance personal educational development by attending training sessions and seminars as appropriate.
Exemplify excellent customer service with tribal stakeholders, health board colleagues, program partners, service recipients, visitors, and guests.
Foster a work environment of wellness, courtesy, friendliness, helpfulness, and respect.
Relate well and work collaboratively with coworkers and all levels of staff in a professional manner.
Consistently demonstrate respect for and acceptance of differing capabilities, cultures, gender, age, sexual orientation and/or personalities.
Maintain and ensure organizational privacy and confidentiality.
Handle crisis and tolerate stress professionally.
Be self-directed and take proactive initiative to assist others.
Resolve issues with other departments and coworkers without direct supervision if needed.
Exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.
Promote an alcohol, tobacco, and drug-free lifestyle.
Embrace modes of appearance and attire that reflect a professional presence.
Adhere to GPTLHB policies and procedures.
Requirements Exemplify excellent customer service with tribal stakeholders, health board colleagues, program partners, service recipients, visitors and guests.
Foster a work environment of wellness, courtesy, friendliness, helpfulness and respect.
Relate well and work collaboratively with coworkers and all levels of staff in a professional manner.
Familiarity and/or experience working with American Indian populations and respect for and knowledge of traditional, cultural and spiritual practices of diverse American Indian communities, as well as an ability to work with other culturally and ethnically diverse populations.
Consistently demonstrate respect for and acceptance of differing capabilities, cultures, gender, age, sexual orientation and/or personalities.
Maintain and ensure organizational privacy and confidentiality.
Must be able to handle crisis and tolerate stress professionally.
Must be self-directed and take proactive initiative to assist others.
Possess the ability to resolve issues with other departments and coworkers without direct supervision.
Able to exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.
Ability to maintain a flexible work schedule, including evenings, weekends and overnight or extended travel as necessary.
Ability to effectively present information in one-on-one and small group situations to community members, consumers and other employees of the organization.
Proficiency with computer programs (Word, Excel, PowerPoint) and other Internet technologies.
Valid driver’s license must be kept current, and certificates, credentials or licenses must be kept current and consistent with regulations required by applicable federal, state and/or grant regulations.
Ability to promote an alcohol-, tobacco- and drug-free lifestyle.
Embrace modes of appearance and attire that reflect a professional presence.
Adhere to GPTLHB policies and procedures.
Supervisory Controls The supervisor assigns work in terms of very general instructions.
The supervisor spot-checks completed work for compliance with procedures and the nature and propriety of the final results.
Work is reviewed through conferences, reports, and observation of PRC operations.
Guidelines Guidelines include state and federal laws, GPTLHB, OHC and department policies and procedures, IHS PRC guidelines, policies and procedures, Medicare/Medicaid policies and procedures, and various third-party payer eligibility and reimbursement guidelines.
These guidelines require judgment, selection, and interpretation in application.
Guidelines include GPTLHB, OHC, and department policies and procedures.
These guidelines are generally clear and specific, and deviations must be authorized by the supervisor.
Complexity/Scope of Work This position consists of varied administrative and technical duties.
The purpose of this position is to support and facilitate operations within the PRC Program.
Contacts Contacts are typically with patients, staff of the OHC, members of the general public, personnel of other IHS facilities, and providers.
Contacts are primarily for obtaining, furnishing, exchanging, and providing factual medical information in order to serve as a liaison to providers and patients.
Work Environment/Physical Demands The work is typically performed while sitting at a desk or table or while intermittently sitting, standing, or stooping.
The work is typically performed in an office and the noise level in the work environment is usually quiet.
While performing the duties of this Job, the employee is regularly required to sit; use hands and fingers to manipulate, handle, or feel; and talk or hear.
The employee must regularly lift and /or move light objects.
Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
The employee must regularly lift and/or move up to 25 pounds and frequently lift and/or move up to 50 pounds.
The employee is occasionally exposed to outside weather conditions.
The noise level in the work environment is usually moderate.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Local and moderate out-of-town travel is required.
Supervisory and Management Responsibility None Education/Experience/Certificates/Credentials High school diploma or equivalent.
Three (3) years of administrative support experience, including one (1) year of experience working in purchased referred care, sufficient to understand and perform the major duties of the position, and to be able to answer questions and resolve problems.
Experience in a health care business office, medical insurance office, social services agency or customer services position is preferred.
Must successfully pass a criminal and background check, and a pre-employment drug screen.
The GPTLHB is a tribal organization which follows tribal preference laws.
It is our policy to give preference to qualified Indian/Tribal candidates over qualified non-native candidates in hiring decisions, if all other qualifications are equal.
Employment is contingent upon the outcome of all required criminal background checks.