Purchased/Referred Care (PRC) & Referrals Specialist

Southern Indian Health Council, Inc•Alpine, CA

1d•$21 - $30•Onsite

About The Position

Under the direct supervision of the Health Information Management Director, the Purchased Referred Care (PRC) & Referrals Specialist initiates the referral process for all patients referred by SIHC providers to healthcare specialty providers for medical, dental, and behavioral health services. This role assists in resolving pre-certification, registration, and case management concerns prior to patients’ appointments, and tracks the progress of all referrals to ensure appointments are kept. The specialist works cooperatively with Medical, Dental, Behavioral Health, and Health Information Management Departments to maintain updated records of all referrals and updates the SIHC referral tracking system. They also work in conjunction with the Billing Department, insurance carriers, social services, and community health systems to assist patients in obtaining appropriate options and funding for specialty care. This position provides referral services for both Alpine and Campo clinics for Medical, Dental, and Behavioral Health.

Requirements

High School diploma or GED certificate.
Two years of medical office experience.
Knowledge of Healthcare Insurance authorization requirements and systems.
Strong customer service focus with effective verbal and communication skills.
Must be organized and able to manage priorities.
Must be highly organized, detailed oriented and a team player.
Must be at least 18 years of age.
A valid driver’s license is required and must be maintained throughout employment.
Applicant must be able to travel throughout the organization’s service area including all SIHC site locations.
Current certifications and/or licenses appropriate to the positions required education and profession.
Reputation for honesty and trustworthiness.
Must be responsible and able to exercise good judgment, accept administrative supervision, pay attention to detail, follow instructions, including the ability to interact effectively and communicate with people in a professional and courteous manner.
Must be highly confidential and work as a team with other staff.
Applicants should be sensitive to client’s needs.
Strong team building, interpersonal, and organizational skills.
Ability to establish and maintain effective peer relationships with coworkers within the Department, clinic-wide, and the public.
Must be able to express ideas clearly, concisely, address audiences effectively, and exercise balanced judgment in evaluating situations and making decisions.
Willing to be part of a team and cooperate in accomplishing department goals and objectives.
Ability to prioritize, meet deadlines, take initiative, be proactive, and function in a rapidly changing environment.
Ability to work with people of all social and ethnic backgrounds, resolve conflicts, negotiate situations, and facilitate consensus.
Normal clinic/office environment.
Sit or stand for long periods of time.
Reach, bend, climb, stoop, lift up to 25 lbs.
Repetitive hand movement; use and view PC.
Reliable transportation and car insurance as required by the state.
Travel as needed.
Each employee plays a key role in creating a compliance culture at SIHC. Employees are expected to learn and comply with all SIHC policies and procedures.
One must have the ability to understand the implications and complexities of all compliance policies.
Participation in all compliance training is mandatory, and generally has a heightened awareness of policies and regulations that are specific to one’s department and position.
All SIHC employees are expected to report violations or suspected violations of compliance policies or regulations.
Applicants must successfully pass a pre-screening tuberculin skin test or x-ray and a blood/urine drug screening test.
Health must be adequate to perform all duties of the position.
Applicants must complete SIHC Application and Authorization Form, both must be submitted to Human Resources prior to the close date indicated.

Nice To Haves

Medical Assistant certification and experience preferred.
Education, training or experience which complements knowledge and skills stated above is desirable but does not substitute for minimum requirements as stated.

Responsibilities

Maintains ongoing tracking and appropriate documentation on referrals to promote team awareness and ensure patient safety.
Reviews referral requests generated by primary care physicians.
Updates SIHC referral tracking systems in cooperation with Health Information Management to ensure specialty reports are received in a timely manner and updates information in the referrals tracking system.
Processes, assembles, and reviews all medical records information concerning patients' managed care for appropriate specialty providers.
Contacts the referred entity and insurance companies to ensure prior approval requirements are met, presenting necessary medical information such as history, diagnosis, and prognosis.
Facilitates appointments for patients and requests follow-up information from specialists.
Contacts patients if an appointment is not kept and assists in rescheduling in a timely manner.
Educates patients regarding referral guidelines and expectations, as well as policies, and provides information about the location of specialist's offices or hospitals.
Reviews rejected requests for procedures or visits and initiates appeals when indicated.
Ensures that referrals are addressed in a timely manner and works closely with Patient Advocates and Community Health Representatives to ensure patients can schedule appointments with specialty providers.
Reminds patients of scheduled appointments via mail or phone.
Attends seminars or training sessions as appropriate for new managed care or social service programs and/or updates on existing programs.
Maintains current knowledge of referral guidelines, databases of active providers, necessary coverage information, and private insurance.
Maintains patient confidentiality and adheres to all HIPAA regulations, ensuring mail, faxes, and medical records are kept confidential and safeguarded at all times.
Maintains a 10-12 referrals submission daily and ensures the accuracy of documents submitted to specialties' offices.
Addresses patient problems/concerns as they arise and provides excellent customer service.
Answers telephone inquiries on matters relating to referrals.
Processes all Purchased/Referred Care referrals for patients in this program.
Determines if clients meet Contract Health Services eligibility requirements for the Purchased and Referred Care program.
Maintains an extensive follow-up system on all Purchased and Referred Care accounts.
Works directly with various medical, dental, and behavioral health business offices and other clinical providers referred to by Purchased and Referred Care.
Arranges transportation for patients/clients to assist them with obtaining necessary documents when applying for an alternative resource.
Receives telephone and written inquiries concerning patients admitted to facilities other than IHS facilities and secures complete data from medical, dental, and behavioral health providers.
Ensures that the patient's SIHC chart is up to date with information on specialist consults/chart notes, labs, hospitalizations, ER visits, and community organizations related to their health.
Tracks Contract Health Services cases through the processes of appointment, procedural scheduling, outcome, and third-party insurance eligibility determination.
Enters PRC invoices and claims on the PRC tracking system.
Educates patients about PRC program eligibility, benefits, and guidelines.
Assists patients in understanding their rights and responsibilities within the program.
Develops and maintains patient education materials and resources.
Stays up to date on program changes and updates, applying this knowledge to patient education.
Ability to work a flexible schedule may be required based on need.
Ability to multi-task and work in a fast-paced environment.
Other duties as assigned.