Referral Clerk

Description

The Referral Clerk provides support services in maintaining a viable managed care services program, which provides eligible beneficiation by non-Indian Health Services vendors and/or in support of direct patient care.

Essential Functions:

• Initiates PRC applications by obtaining information from patients, family members (relatives), provider staff within IHS, and professional and non-professional staff from outside private providers. The information required to update the patient's registration database includes income information, third-party information, and any other information required to ensure the patient meets the five eligibility factors of PRC Program.
• Educates patients or providers on the PRC eligibility factors.
• Prints updated face sheet off of Patient Registration and completes verifications off of the AZ AHCCCS and Medicaid terminals. Logs in all PRC applications/notifications by date of service.
• Provides patient education on the different alternate resources that are available to patients, and assists with application process.
• Routes all PRC applications/notification to Director of Clinical Operations for medical necessity review.
• Ensures that issuance of purchase orders and/or denials are within specified time limits. Ensures that consistency and correct use of allotments, object, sub-object and sub-activity coding required by Area Financial Management are utilized. Performs periodic spot reviews and follow-up of completed purchase delivery orders.
• Ensures, all completed purchase delivery orders are paid; follows up with provider and assists in closing out purchase order.
• Maintains a DCR (Document Control Register) on all purchase orders issued. Prints and sends out a quarterly provider Opened Document Report for follow-up and status of all obligations.
• Maintains office files according to established functional files system. Searches for and withdraws material, as requested.
• Generates AHCCCS referrals to providers which are AHCCCS providers and those that are denied PRC, maintains copies of these in the PRC case file.
• Assists with submitting and closing out CHEF cases (Catastrophic cases) to ensure reimbursement.
• Makes Emergency transport arrangements requested from the Emergency Room or other inpatient/outpatient wards, coordinates information with receiving and sending facilities and/or nurses and physicians; contacts air medical transportation or the ground medical transportation.
• Maintains a transportation log for all medical transports that take place on a monthly basis.
• Provides information by telephone and personal inquiries regarding payment, outstanding charges, eligibility, etc. Ensures that medical confidentiality is maintained in all contacts conducted. Prepares response to routine correspondence.
• Gathers information and prepares certain PRC cases concerning eligibility, denials, appeals to Area Office and Administration.
• Posts all paid/disbursed obligations off the EOBR'S (Explanation of Benefit Records) from the medical insurance provider.
• Reconciles the PRC System weekly and monthly
• Preform other duties as assigned.

Requirements

• At least 6 months of related experience.
• High School Diploma or GED equivalent.
• Associates Degree, preferred

Indian Preference and Equal Employment Opportunity

SCAHC gives preference in hiring to San Carlos Apache Tribal members and other Native Americans in accordance with the San Carlos Apache Tribe's Tribal Preference Policy, as set forth in Section 402 of the Tribe's Human Resources Department Policies and Procedures Manual. Otherwise SCAHC does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect him/her because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, citizenship, veteran status, military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, SCAHC complies with all applicable federal, and Tribal laws governing nondiscrimination in employment.