PURCHASED REFERRED CARE MGR

The Pueblo of Sandia•Rio Rancho, NM

2d•$26 - $32

About The Position

Provides case management, support and technical assistance to patients seeking Purchased/Referred Care (PRC). This position plans, implements, coordinates and monitors all purchased/referred care within the Pueblo of Sandia. Our philosophy is built on the principles of integrity, fairness, collaboration, communication, and recognition for performance excellence. Meeting all performance standards leads to attracting and retaining a qualified workforce, provides opportunities for qualified team members, and contributes towards the ongoing success of the Pueblo of Sandia today and in the future.

Requirements

High School Diploma, GED certification or equivalent
Three (3) years of hospital, medical office or other health care related experience.
Three (3) years familiarity with medical terminology, insurance verification and/or purchased referred care process.
Three (3) years knowledge of UB04, CMS1500, ADA claims forms and explaination of benefits.
CPR/1st Aid certifications
PE/MOSAA Certification
Must be able to successfully pass a stringent background investigation and character investigation in compliance with PL 101.630.
Will require a pre-employment and random drug screening.
Must possess and maintain a valid, unrestricted New Mexico Driver’s License.

Nice To Haves

Intermediate knowledge of medical terminology preferred.
Knowledge of Medicare, Medicaid, Workers Compensation and other health care resources preferred.

Responsibilities

Provides lead support to the back of the PRC office patient referral process.
Confirms eligibility for Sandia PRC services with consideration of factors including, but not limited to,Tribal membership, tribal descendent status, patient age, place of residence, availability of alternative resources and student status.
Identifies alternate medical resources available to patients, including but not limited to Medicare, Medicaid, Veterans Administration, Workers Compensation and Patient Assistance Medication Coverage.
Prepares additional liability forms as necessary.
Maintains consistent communication with external billing staff to ensure appropriate case monitoring and management practices are in place for continuous continuity of care through completion of PRC services.
Resolves outstanding open approved referrals and open PO issues in a timely manner.
Maintains new and existing outside provider contracts.
Assists in gathering information for the preparation and submission of Catastrophic Health Emergency Fund (CHEF) applications.
Maintains the privacy and confidentiality of patient information in accordance to the Privacy Act, Health Insurance Portability and Accountability Act (HIPAA), Electronic Health Record (EHR) system policies and procedures.
Responsible for reviewing relevant PRC cases and compiling, analyzing and verifying statistical data.
Procides guidance to patients and their families on eligibility and other aspects of the PRC Program.
Develops and organizes orientation materials for patients, families, and hospital staff regarding PRC procedures and services.
Examines completed claims submitted by vendor for accuracy of incoming charges associated with an approved referral.
Completes Purchase Order (PO) request in RPMS system in a timely manner for processing of payment through the Tribal Finance department weekly.
Call the vendor/providers office with any unclear or incomplete claims submission.
Verifies that services rendered align with contract terms and enters data to maintain accurate system operations.
Communicates with PRC providers to explain IHS policies and contract care procedures.
Fosters a cooperative working relationship with contract terms and enters data to maintain accurate system operations.
Communicates with PRC providers to explain IHS policies and contract care procedures.
Prepares and sends correspondence to patients, healtcare providers and other agencies regarding eligibility , policies and regulations including claim denial letters.
Ensures the confidentiality of patient information and maintains records of denials, deferrals and appeals for reporting purposes.
Oversees the upkeep of commitment registers, which serve as a daily log of processed obligations.
Reviews automated data against manual records, identifies any discrepancies, determines their source and implements appropriate corrective actions.
Provide services supporting the PRC Department and all functions within to include referrals, claims and alternate resources/patient benefits to qualified individuals in the Pueblo of Sandia health plans.
This position provides support services to the Health Center PRC program and all related services in maintaining a viable program that demonstrates compliance with policy and regulations.
Performs other related duties as assigned by the supervisor.
Creates an environment of teamwork though strong communication, mentoring, and providing guidance, support, and appreciation for team members contributions
Performs special projects and other job-related duties as assigned.