Job Title: Purchased and Referred Care (PRC) Technician

Department: Health Clinic

Reports To: Medical Business Office Manager

Job Status: Regular/Full Time

Type: Non-Exempt

Grade: F

JOB SUMMARY:

This position is to manage, plan, direct, and coordinate business activities of the Purchased and Referred Care Program

MAJOR TASKS AND RESPONSIBILITIES:

• Acquire AFA (Annual Funding Agreement) information from administration to set up Purchased/Referred Care Register for the year.
• Consistently meet deadlines for processing denials or payment of claims.
  • Notifying vendors within 5 business days of acceptance of claim for processing.

  • Providing account status and updates to clients upon request.

  • Completing the payment cycle within 30 business days of receipt.
• Set up Commitment Register to enable the issue of Purchase Orders for patients/providers outside the facility.
  • Requires knowledge of RPMS
• DAILY:
  • Check MIP for check register to verify if payments have been processed.

  • Check email for communications from Shasta for hospital requests.

  • Screen incoming mail for:
• Alternate resource information, proper eligibility, communicate with providers.
• To upgrade or add new providers, acquire W9 from providers and enter in to RPMS.
• Enter all information related to a member's application in RPMS following security and privacy standards established by the Health Insurance Portability Accountability Act (HIPPA).
• Maintain daily, monthly and quarterly statistics, approvals and denials of all claims.
• Coordinate the methods and systems established for identifying and referring patients for use of Third-party resources.
• Coordinate operation of the PRC program, to include; technical PRC advice and assistance to staff and providers, and providing information to patients about PRC.
• Calculate Medicare Like Rate eligible invoices, prepare and issue appropriate purchase orders or denials with supporting medical justification.
• Answer telephone and written inquiries regarding eligibility requirements, payments, outstanding charges, and other questions concerning the PRC Program.
• Prepare routine correspondence, and compile information for periodic special reports.
• Enter data obtained from Purchase Orders in RPMS System; file and maintain documentation.
• Maintain a Spreadsheet of all denials and other correspondence sent out via standard mailing.
  

OTHER DUTIES:

Because of the Tribe's commitment to community service and the well-being of its members, each employee may be expected to perform a wide range of office and field duties from time to time. Such duties may or may not be related to their regular responsibilities.

PREFERENCE:

• Indian Preference Policy applies to this and all positions with the Nooksack Indian Tribe.
  

MINIMUM QUALIFICATIONS

The following qualifications are required for the incumbent to have, in order to be considered for the position.

REQUIRED EDUCATION, EXPERIENCE AND TRAINING FOR POSITION:

• High School Diploma or equivalent (GED)
• Associates degree in Public Health or related field; or
• 4 years of experience in a health care setting or equivalent position preferably in tribal government, finance and health department
  

REQUIRED SKILLS/KNOWLEDGE/ABILITIES POSITION:

• Must demonstrate working knowledge of: Federal Privacy Act and Federal HIPPA regulations; Medicare, Medicaid, ACA, and a variety of health insurance carriers; and tertiary payment methods.
• Must be familiar with Electronic Health Records.
• Must be computer literate with specific working knowledge in Microsoft Office.
• Must have the ability to apply common sense and critical thinking skills when carrying out written and oral instructions.
• Must have the ability to effectively deal with a variety of interruptions that may arise during the course of performing employment essential duties.
• Must have knowledge of Tribal and Federal Government funding programs such as Indian Health Service (IHS), Purchased/Referred Care (formerly Contract Health Service - CHS) , Community Health Service, Medicare, Medicaid and the Washington State Insurance Market Place.
• Must continuously maintain a courteous and professional rapport with the patients, clients and staff of the Nooksack Tribal Community.
• Must be respectful and sensitive to the values and culture of the Nooksack Indian Tribal Community .
  

REQUIRED CONDITIONS OF EMPLOYMENT:

• Must pass alcohol/drug test at time of hire and throughout employment.
• Must pass criminal background check at time of hire and periodically thereafter.
  

REQUIRED LICENSES OR CERTIFICATIONS:

• Must have and maintain throughout employment a valid Washington State Driver’s License and meet the insurability requirements of the Tribe. (Must Provide Driving Abstract at time of hire).
  

PHYSICAL REQUIREMENTS ( The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.):

• Potential for exposure to blood-borne pathogens and communicable diseases.
• Occasional standing/walking while performing office duties; walking short distances throughout shift on tile, carpet or concrete.
• Frequent-constant sitting on adjustable chair at desk or assigned work area. May stand as desired.
• May kneel or crouch occasionally to retrieve items from ground level.
• Work requires stooping, crouching, reaching, pushing, pulling, grasping and repetitive motion. Job requirements include forward and over shoulder reaching on a frequent basis.
• Ability to use computers, phone, calculator, copier and other office equipment.
• Constant use of hands, fingers and arms to reach or grasp while using office equipment, and for other administrative duties.
• Ability to Multi-Task: e.g., answer phones, and effectively interact with clients, patients and co-workers while giving and receiving instructions.
• Ability to speak and hear clearly; visual requirements include hand-eye coordination, visual acuity in near/mid rages, frequent depth perception, peripheral vision, color discernment and accuracy.
• Frequently lift or move up to 25 pounds.
• Work is primarily performed indoors in a climate controlled office environment.