Purchased Referred Care Claims Analyst

Tuba City Regional Health Care Corporation•Tuba City, AZ

4d•Onsite

About The Position

This position is considered an expert in Purchased Referred Care (PRC) and is a key resource for team members. The PRC Claims Analyst works closely with department leadership to monitor program compliance, budget, reports, and claims accuracy by performing the following: monitoring fund control and appropriate use of dollars spent on allowed services, auditing claims processed for patient eligibility for third party programs, and ensuring proper codes are submitted to cover primary provider, diagnosis, and clinic. The PRC Claims Analyst performs high-cost case management of expenditures to determine cases that may include catastrophic illnesses; and performs repricing claims to Medicare Like Rates.

Requirements

High School Diploma or GED
Must have 5 years of general clerical experience that includes data entry and providing customer service.
Must have 5 years of experience in clinical / medical setting.
Must have 5 years of experience in PRC, Revenue Cycle, Patient Benefits in any combination or separately to equal the 5 years of experience.
Must have 1 year of experience in budgeting to include assuring funds have been obligated within deadlines, maintaining weekly spending plan, processing claims for payment to vendors.
Must have medical terminology course completion. Navajo Medical Interpreter certification may substitute for general medical terminology course completion.
Experience in repricing PRC claims at Medicare Like Rates (will be clarified during interview process)
A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:
Fosters teamwork and positive working relationships with others
Possession of high ethical standards and no history of complaints
Reliable and dependable; reports to work as scheduled without excessive absences.
Effective communication skills to deal effectively with all levels of co-workers.
Ability to multi-task, prioritize and manage time to strict deadlines.
Must be proficient with typing and accurate spelling/grammar.
Completion of an above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job.
Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job.
Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job.
Submission of all required employment-related documents, application, resumes, references, and other required information free of false, misleading, or incomplete information, as determined by TCRHCC.

Nice To Haves

Navajo Medical Interpreter certification may substitute for general medical terminology course completion.

Responsibilities

Welcome & greet patients/visitors in person and/or the telephone; answer or refer inquiries; direct patients/visitors; document calls and visits into PRC management software; record and deliver messages to appropriate personnel. Politely communicate with respect to patients and families during time of emotional, mental, and physical stress.
Receive, stamp date daily patient referrals/notifications from patients, TCRHCC providers, and/or other facilities. Review referrals against TCRHCC electronic medical records to determine if patient meets PRC eligibility criteria ensuring applicable processes, make independent decisions confidently, and must be able to support decisions and/or purpose of actions taken.
Notate referral approval/denial status to clinic providers or clinic CST staff who may schedule appointments and follow up on referrals to obtain appointment date and time. Mail referral and PRC letter to patient with their appointment date and time.
Forward referrals for non-TCRHCC patients to appropriate service unit within 72 hours of receipt.
Identify notifications and attach appropriate cover sheet including any supporting documentation, i.e., TCRHCC Patient Face Sheet, Arizona Health Care Cost Containment System (AHCCCS) verification forms, obtain/copy of any other alternate resources, claims, medical notes, etc. Compile corresponding documents and input pertinent data into system to establish case record and obtain a referral.
Research the electronic health record (EHR) to identify existing medical records for patient and date of service (DOS) per notification to prevent duplication of records. Note case number on notifications and other documents for quick referencing and forward to Caseworkers for processing.
Responsible for daily data entry of referrals/notifications into the PRC management software; establish patient records and processing claims.
Educate patients/clients of PRC scheduling process and obtain necessary documents such as PCC visit notes, lab report and radiology report. Explain PRC rules and regulations, eligibility, policy/procedures. Conduct reviews on a periodic basis to ensure proper and timely follow-up.
Interview patients and/or family members to determine potential eligibility for any alternate resources and make the necessary contact with the identified resources. Enter notes and actions taken for each record, i.e., phone calls, providers, purposes, etc.
Administer the day-to-day activities required of the PRC program by initiating PRC medical purchase orders/claims payments. Assure the issuance of purchase orders/claims payments to providers are within specified time limits. Maintain files of all correspondence for future confirmation and/or referencing. Provide information to HIM of patient’s name and name of receiving facility for accidental injuries and Tort Claims.
Maintain professional skills by attending in-services, workshops and participates in continuing education.
Maintain weekly spending plan, staying within PRC allocated budget, assisting with reports regarding cases, claims, budget expenditures.
Review determinations and claims for accuracy, report any discrepancies, make corrections as needed.
Work closely with Care Coordination Team members to ensure continuity of patient care, update team members and attend department huddles as required.
Work closely with PBC staff to ensure patients are connected to alternate resources.
Work closely with departmental leadership to monitor program compliance, budget, reports, and claims accuracy by performing the following: monitoring fund control and appropriate use of dollars spent on allowed services, auditing claims processed for patient eligibility for third party programs, and ensuring proper codes are submitted to cover primary provider, diagnosis, and clinic.
Perform high-cost case management of expenditures to determine cases that may include catastrophic illnesses.
Perform repricing claims to Medicare Like Rates
Ensure proper PPE is always worn while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, and eye or face shield as required.
Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly. (see CDC website for most current updates).
Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a prominent level of patient, visitor, employee, and external customer satisfaction.
Performs other duties as assigned.