Job Description

Posting number: 100940-261005

Department: Health & Human Services

Division: HHS-Administration

Job classification: Purchase/Referred Care (PRC) Coordinator

Posting type: Open & Promotional

Categories: Health Services

Summary

Under general supervision of the Purchase Referred Care (PRC) Manager, the Purchase Referred Care (PRC) Coordinator assures PRC fiscal accountability working closely with various departments to ensure coordination between the referring Primary Care Provider (PCP) and specialists, Responsible for determining PRC eligibility and coordinating specialty medical services for the Salt River Pima-Maricopa Indian Community (SRPMIC) when services are not available at SRPMIC. The PRC Coordinator serves as an advocate for patients being referred for outside SRPMIC services. This job class is treated as FLSA Non-exempt.

Essential Functions: Essential functions may vary among positions and may include the following tasks and other characteristics. This list of tasks is ILLUSTRATIVE ONLY and is not

Examples of duties

• Screens all medical referral/case for PRC eligibility
• Ensures all eligibility factors are met prior to obligating/authorizing PRC funds
• Coordinates referrals and appointments with medical specialists timely, including determining patient’s health care payment and eligibility resources; but not limited to: sending all medical notes, patient demographics, and insurance information to the outside vendor; confirms faxed referral is received by the specialists office, track the patient appointments to completion; following up with the outside vendors to ensure patient records are received
• Makes timely decisions to approve or deny a referred request
• Monitors progress in improving the referral billing and claim process to close out purchase orders (PO) for medical services rendered
• Assist patients and families in understanding eligibility and program limitations, documents patient education
• Refers patients to the Benefit Coordinators (BC) to be screened or to apply for alternate resources when they are potentially eligible and follows up with documentation effort
• Maintains compliance with Salt River Pima-Maricopa Indian Community Purchased/Referred Care policies and procedures to include the maximum utilization of alternate resources and to promote fiscal responsibility
• Keeps track of referrals for potential AHCCCS eligible and affirms or reverses decision of payment based on the Benefit Coordinator screening or DES application.
• Ensures all medical referrals are entered accurately into the referral management system(s).
• Ensure accurate data entry to obtain meaningful data/reports. Maintains accurate and current electronic record keeping system for PRC program. Miscellaneous: Performs other job-related duties as assigned by the supervisor.
• Other job-related duties as assigned to maintain and enhance department operations.

Knowledge, Abilities, Skills and Other Characteristics:

• Knowledge of the history, customs, culture and traditions of the Salt River Pima-Maricopa Indian Community.
• Knowledge of the federal Freedom of Information Act, Privacy Act and HIPAA laws as they pertain to the SRPMIC work environment.
• Knowledge of PRC programs and regulations.
• Knowledge of RPMS, RCIS, BCBS Fiscal Intermediary (FI), EPIC, AHCCCS online, Novitas and other insurance eligibilitysystems.
• Knowledge of various clinical systems, walk-ins and appointments to avoid unnecessary delay and/or confusion on the part of patient.
• Knowledge of various medical services offered by the clinic.
• Knowledge of patient business functions and processes to augment Third Party Billing activities and routines.
• Knowledge of medical terminology and medical care practices and procedures.
• Knowledge of CPT, ICD-10, HCPCS and dental coding and billing.
• Knowledge of alternate resource: State Medicaid (AHCCCS), Medicare, Medicare Advantage Plans, Private insurance, Tribal Self-Insured insurance plans and other related programs,
• Skill with personal computer e.g. Outlook, Word, Excel, Powerpoint, Teams.
• Skill communicating orally and in writing to gain confidence of patients.
• Ability to be dependable in attendance and job performance.
• Ability to multitask and perform well under pressure.
• Ability to accept and learn from supervisor/peer critique.
• Ability to answer intelligently, tactfully and accurately the questions raised by patients.
• Ability to handle confidential and sensitive information.
• Ability to communicate effectively on the telephone or in person.
• Ability to exercise good judgement in calls or personal contact with patients.

Qualifications

Education & Experience: High School or GED equivalent required and two (2) years’ experience in customer service and/or related healthcare environment. Medical billing and/or terminology experience preferred. An Associate’s Degree or related healthcare certification is preferred.

Equivalency: Any equivalent combination of education and/or experience that would allow the candidate to satisfactorily perform the duties of this position, will be considered.

Underfill Eligibility: An enrolled Community Member who closely qualifies for the minimum qualifications for a position may be considered for employment under SRPMIC Policy 2-19, Underfill.

Supplemental information

May be required to work beyond normal work hours including nights, weekends and holidays.

Employees in, and applicants applying for, jobs providing direct services to children are subject to the “Community Code of Ordinances”, Chapter 11, “Minors”, Article X. “Investigation of Persons Working with Children”.

Ensures all patient information is kept confidential and complies with Health Insurance Portability and Accountability Act (HIPAA) regulations and SRPMIC HHS policies and procedures.

Prior to hire as an employee, applicants will be subject to drug and alcohol testing. Will be required to pass a pre-employment background/fingerprint check.

"SRPMIC is an Equal Opportunity/Affirmative Action Employer" Preference will be given to a qualified: Community Member Veteran, Community Member, Spouse of Community Member, qualified Native American, and then other qualified candidate.

In order to obtain preference, the following is required: 1) Qualified Community Member Veteran (DD-214) will be required at the time of application submission 2) Qualified Community Member (must provide Tribal I.D at time of application submission),3) Spouse of a Community Member (Marriage License/certificate and spouse Tribal ID or CIB is required at time of application submission), and 4) Native American (Tribal ID or CIB required at time of application submission).

Documents may be submitted by one of the following methods:

1) attach to application

2) email to HRRecruitment@srpmic-nsn.gov

3) fax (480) 362-5860

4) mail or hand deliver to Human Resources.

Documentation must be received by position closing date.

The IHS/BIA Form-4432 is not accepted.

Your Tribal ID/CIB must be submitted to HR-Recruitment-Two Waters.