Purchased Referred Care (PRC) Specialist

Job Description

Job Description

POSITION PURPOSE

The PRC Specialist works closely with medical provider by way of coordination of care, management of benefits, approvals of services based on IHS/PRC eligibility guidelines, to provide the best customer service and assistance to the population that we serve. The PRC Specialist will maintain confidentiality, accuracy, and professionalism in all interactions to help facilitate timely access to care and maintain compliance with tribal, federal, and facility policies.

ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all inclusive.

· Coordinate referrals and appointments with medical specialists, including determining patient’s health care payment and eligibility resources, but not limited to: Obtaining all insurance pre-authorization necessary for the referral; sending all medical notes, demographics and billing information to the outside vendor; tracking the patient appointments to completion; arranging for transportation if needed; following up with the outside vendors to ensure patient records are received at our facility; and ensuring that patient has proper follow-up until medical care is complete.

· Assists in assuring patient eligibility meets the IHS/PRC guidelines. Verifying all alternative medical insurance resources are utilized prior to providing PRC services.

· Ability to utilize outside portal to verify appointments, print clinical notes and imaging reports.

· Help staff verify insurance eligibility through appropriate portals.

· Accurately and consistently, in a timely manner, enter all PRC appointment data into the RPMS system in accordance with EMHC PRC requirements

· Ability to thoroughly document referral status and payment information related to active, open and closed referrals

· Ability to enter in referrals for ER/Urgent Care patients in a timely manner

· Ability to utilize outside portal to verify appointments, print clinical notes and imaging reports.

· Work daily with invoicing of PRC claims, and the posting of payments

· Provide answers to referring physicians, and those responsible for their billing, when inquiring about payment status.

· Work with outside billing vendors on requesting claims from patient billing statements

· Maintains accurate and current electronic record keeping system for PRC program.

· Follow HIPPPA guidelines, Privacy Act, and other applicable confidentiality standards; uphold highest standards of privacy and confidentiality.

· Represents HHC with dignity, integrity, and a spirit of cooperation in all relationships with staff and the public.

· Perform other duties as assigned to support the goals and efficiency of the department.

MINIMUM MANDATORY QUALIFICATIONS:

· High school diploma / GED

· Experience working in a Tribal Program

· Must have one-year experience in office or health care setting

· An understanding and knowledge of private, state, and federal health insurance practices as it pertains to process patient in-coming claims.

· Familiarity with Acoma Pueblo culture, values and traditions.

MANDATORY KNOWLEDGE, SKILLS, ABILITIES & OTHER QUALIFICATIONS:

Knowledge of:

· Proficient in Microsoft Office (Word, Excel, Outlook) and electronic health record systems

· Must have basic knowledge of Resource Patient Management System (RPMS)

· Knowledge of medical terminology

· An understanding and knowledge of private, state, and federal health insurance practices as it pertains to process patient in-coming claims.

· Experience in medical billing in both ambulatory and hospital settings

· Must pass a Criminal Records Background Check

· Must pass and submit to an Alcohol/Drug Screen and random testing as per policy

POSITION PREFERENCES

· Prior experience working with a tribal organization.

· Native American Preference.

· Familiarity with Acoma Pueblo culture, values and traditions.

· Bilingual skills in English and the Keres native language.

Haak'u Health Center, formally Acoma/Canoncito/Laguna (ACL) Clinic is now hiring! Please consider joining the Haak'u Health Center team.

Company Description

Haak'u Health Center, formally Acoma/Canoncito/Laguna (ACL) Clinic is now hiring! Please consider joining the Haak'u Health Center team.