Purchased/Referral Care Resource Coordinator

Job Description

Job Description

Position Summary :

Under the direction and supervision of TRIHCI’s PRC Officer, the PRC Resource Coordinator is responsible for the coordination of all assigned patient referrals and medical specialty services, including referrals to hospitals, hospices, home health services, dental services, etc. In this capacity, the PRC Resource Coordinator is responsible for obtaining prior authorization when needed, and common workflow responsibilities will also include monitoring referrals, generating purchase orders, and processing bills for payment with proper medical coding. Consequently, this position requires someone who is an independent worker yet remains committed to a team-orientated approach. He/she must be sensitive to the needs of the Indian community; its cultures, traditions and values and express a genuine enthusiasm for its well-being.

Essential Duties and Responsibilities :

1. Adds, edits, and updates appropriate patient referral information in TRIHCI’s RPMS and Next Gen system.
2. Monitors and guides the process of securing and delivering patient referrals for a variety internal and external specialty services, including optical, dental, medical, hospital, hospice, home health, radiology, DME and/or other services.
3. Coordinates the compilation, flow, and maintenance of information relating to patient referrals, including verification of patient eligibility, patient benefits, alternative resources identification and utilization, contract and network provider status, and other documentation (e.g. radiology reports, labs and tracking of DME supplies, ie hospital beds, wheelchairs and incontinent supplies, etc.).
4. Responds to, assists, and manages patient inquiries regarding their initial or follow-up appointments, referral requests, purchase orders, transportation options, PRC or IHS regulations, or other related issues in a courteous and professional manner.
5. Maintains strong relationships with the professional medical community and updates information relating to Health Plans or payers regarding referral requests and patient options.
6. Works collaboratively with clinic staff, Patient Services Representative, and our Patient Benefits Coordinator to ensure appropriate referrals are being made, registration is current and up to date and alternative resources are being explored in accordance with PRC guidelines.
7. Receives and processes bills and/or purchase orders for payment, Claims are repriced through a website to automate the PRC Rate with proper fiscal procedures, including elements of proper coding and RPMS entry and maintains appropriate logs for claims tracking.
8. Serves as an internal and external resource for all issues relating to PRC processes, referrals, insurance information, purchase orders and related information at TRIHCI.
9. Reviews and submits outgoing letters, faxes, memos, and/or other correspondence as needed to support the provision of effective patient care.
10. Serves as a primary representative of the PRC department at assigned clinic and community outreach activities.
11. Participates in the TMAA claiming process.

Additional Responsibilities may include :

1. Participates in all required staff meetings and trainings.
2. Performs all other duties as assigned.

Qualifications : To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed here are representative of the knowledge, skills, and/or abilities required. In accordance with the Americans with Disabilities Act (ADA), reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Knowledge, Skills, and Abilities

1. Possess strong organization competencies, particularly in the areas of records management and patient registration.
2. Demonstrate excellent interpersonal skills and the ability to interact effectively with a wide variety of individuals.
3. Demonstrates functional understanding of alternative resources identification and utilization.
4. Possess basic knowledge and skill in EHR software and database management.
5. Demonstrate basic levels of computer literacy, with a functional understanding of Microsoft Windows Operating Systems in an office setting.
6. Maintain a basic knowledge of ICD-10 and CPT coding, as well as basic medical terminology.
7. Demonstrate dependability and punctuality in carrying out work assignments.
8. Must have the ability to work under pressure in dealing with multiple tasks and constant deadlines, while maintaining attention to detail and accuracy.
9. Must have good communication skills and be able to effectively communicate with diverse populations.
10. Demonstrate the ability to work independently in carrying out assignments while remaining reliable and dependable.

11) Possess the ability to perform well in group problem-solving situations and use reason even when dealing with highly emotional topics.

12) Possess the ability to become knowledgeable of health needs and services provided to the Indian community both on and near the reservation.

13) Demonstrate the competency and integrity to maintain the confidentiality of organizational, employee, and client records.

Education and/or Experience

A high school diploma or GED-equivalency is required for this position. Three (3) years prior experience in an ambulatory health care setting is also required. Advanced or specific training in Purchased/Preferred Care or Indian Health Services functions is preferred.

Certificates, Licenses, Registrations

A current California driver’s license, a good driving record, and BCLS certification are required for this position or must be obtained with 3 months of employment.

Preferred Qualifications and Contingencies

Advanced or specific training in Purchased/Preferred Care or Indian Health Services functions is preferred. Four (4) to six (6) years related experience is also preferred.

TRIHCI maintains a drug- and alcohol-free workplace, and all offers of employment are contingent on the successful completion of a criminal background check, a post-offer drug test and physical, and TB test, and verification of each candidate’s right to work in the United States.

Preference in hiring is given to qualified American Indians in accordance with the Indian Preference Act (Title 25, U.S. Code, § 472 & 473). Applicants claiming Indian Preference must submit Indian verification, certified by Tribe of affiliation or other acceptable documentation of Indian heritage.

Physical Work Environment : The description provided here is representative of those conditions in which the PRC Resource Coordinator will be required to perform the essential functions of this position. As stated earlier, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.

While performing the duties of this position, the PRC Resource Coordinator is situated in a standard office environment within the health center, where there is little or no exposure to variations in the weather or other similar elements. The PRC Resource Coordinator will move throughout the health center to meet with supervisors and co-workers but maintains limited direct patient/client contact. Consequently, the PRC Resource Coordinator must:

1. Possess the mobility to work in a standard office setting (i.e. walk, stand, or sit for extended periods of time).
2. Posses the ability to use standard office equipment to write, type, copy, fax, or perform other duties;
3. Possess the strength to lift and carry supplies weighing up to 10 lbs repeatedly and up to 25 lbs intermittently.
4. Possess the visual acuity to read printed materials and a computer screen; and
5. Demonstrate hearing and speech capabilities that allow him/her to communicate in person and over the telephone as required.

The clinical setting at TRIHCI is categorized by OSHA as a Blood-borne Pathogen Category I facility. Consequently, there exists the potential for exposure to blood, body fluid/tissue, and infectious wastes. There also exists the potential for exposure to chemicals, biologicals, toxicants, and irradiants found on-site.

Disclaimer:

This position description lists the major duties and requirements for the PRC Resource Coordinator position as established by subject-matter experts at the time of this document’s creation. This position may require additional performance of duties and responsibilities beyond those outlined in this document, and thus may require additional sets of knowledge, skills, and abilities not fully articulated herein.