PURCHASED REFERRED CARE (PRC) SPECIALIST

NAVAJO HEALTH FOUNDATION - SAGE MEMORIAL HOSPITAL, INC.•Ganado, AZ

9d•Onsite

About The Position

The Purchased Referred Care Specialist (PRC Specialist) will provide services supporting the PRC Department and all functions within to include, referrals, claims, non-emergent medical transportation, alternate resources/patient benefits to qualified individuals in the managed health care plan administered by the Navajo Health Foundation/Sage Memorial Hospital (NHF/SMH). This position provides support services to the Purchased Referred Care Department and all related services in maintaining a viable program that demonstrates compliance with policy and regulations. This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Requirements

High School Diploma or General Equivalency Diploma.
One (1) year of hospital, medical office, or other health care related experience.
One (1) year familiarity with medical terminology, insurance verification, and purchased referred care process.
Must be able to successfully pass the Employee Health Program requirements and background investigation.
Excellent customer relations and telephone skills is a necessity.
Ability to work in a high stress environment performing tasks requiring attention to detail and precision.
Ability to work independently and follow tasks given by supervisor.
Ability to perform work duties in a competent manner with a sense of urgency.

Nice To Haves

Ability to speak the Navajo language.
Ability to speak the Navajo language and/or familiarity with the Navajo Way.
Ability to successfully utilize office equipment such as e-fax, manual fax machines, and scanners

Responsibilities

Review all new urgent, routine and stat referrals, determine eligibility based on PRC Guidelines, notify patient of determination, identify vendor, send vendor authorization/denial form and referral packet, note activity in EHR
External referrals from IHS-638 facilities, import referral packet into EHR by creating a new case or referrals, follow eligibility guidelines to make determination, notify patient of determination, identify vendor, send vendor authorization/denial form and referral packet, note activity on the new case in EHR
Develop and maintain a working knowledge of Arizona Health Care Cost Containment System (AHCCCS) rules and regulations and the terms and conditions of all NHF/SMH Managed Care contracts.
Determine third party payer resources and eligibility of individuals for NHF/SMH managed care program using all sources of information available, including the NHF/SMH computer system.
Upon access to HEA+, assists individuals with benefit enrollment, applications, submissions
Receive requests for prior authorization of services and respond according to AHCCCS.
Complete, maintain, compile and report accurate manual and electronic documentation of all job-related activities in NAIHS system and spreadsheets.
Upon receipt of paper claims, enter claims into PRC software for processing and subsequent payment
Reprice and adjudicate claims so they can be paid timely as per the Prompt Payment Act
Electronic claims adjudications, repricing and payment; to include case creation in PRC software to reconcile referral to electronic claim
Create cases for referrals and notifications that originate outside of the SMH OPD department (Emergency Room, Inpatient, IHS-638 facility, transfers out of SMH via ground or air emergency transport and self-referral notifications)
Complete assigned worklist/workload on a daily basis per departmental productivity requirements
Determine eligibility, create referral case, send referral and create letters in real time (same day during patient PRC office appointment) for patients who are seen in-person following their OPD visits or as walk-ins
Identify, track and notify PRC Team Lead when a patient is reaching the PRC Catastrophic Health Emergency Fund (CHEF) threshold
Assist PRC Team Lead with compiling required documents for CHEF case submission through the Indian Health Service Office of Resource Access and Partnerships (IHS ORAP) ECA CHEF Online Tool
Create and process referrals in PRC Nivonyx Software from case creation, referral submission, claims data entry through repricing claim, then sent to PRC Team Lead / Director for final audit and payment batch processing
Compile referral and claims data for workload tracking; complete reports as requested from leadership
Serve as preceptor to assist with new staff training
Rotate coverage for other roles in the department during staff shortages, increases in workload, and special projects
Consult with immediate supervisor guidance and support in communicating medical management decisions, as needed.
Assist patient and NHF/SMH staff with arranging prior authorization for non-emergency medical transportation and meals/lodging for AHCCCS qualified patients.
Research patient and provider grievances; compile the information gathered and submit to immediate supervisor for a decision.
Participate in and attend all required in-services and educational programs to improve and/or learn job-related skills.
Uphold all principles of confidentiality and patient care according to NHF/SMH policy and procedures.
Maintain communications with IHS and non-IHS facilities regarding patient referrals.
Maintain PRC files according to established filing system.
Receive patient/vendor notifications for medical services.
Participate in and contribute to NHF/SMH and departmental quality improvement initiatives.
Gather information on sensitive PRC cases for eligibility, denials, appeals and submit to immediate supervisor for review/approval.
Provide administrative support to the immediate supervisor.
Cross train and cover for other staffing roles in the department as needed or as assigned
Perform other duties as required.