PRC Representative (Optical/Dental/Medical)

Grand Traverse Band of Ottawa and Chippewa Indians; Northern (KY); Hybrid; USD 26,000 - 32,000; Full time

Benefits offered by this job

Major Medical

Dental

Prescription

Vision

Life Insurance

401(k) Plan

PTO

Holidays

Short/Long-Term Disability

AFLAC

Job summary

Grand Traverse Band of Ottawa and Chippewa Indians is hiring for a Health Services coordinator to assist in administration of Purchased/Referred Care services and related systems. You will manage FCP Gateway, RPMS, and COB processes, serving as a liaison among clients, providers, and the Third-Party Administrator.

The role covers three counties within the GTB 6 County Service Area, focusing on eligibility, claims status, and enhanced customer service.

Qualifications

• Must have a High School diploma or GED.
• Minimum of one-year post high school education in Business Administration or health related fields, or demonstrated experience understanding coordination of benefits.
• Equivalent experience may be considered in lieu of education.

Responsibilities

• Maintain the FCP Gateway and RPMS systems for client, vendor, budget, and commitment files.
• Process prior authorizations for PRC across medical, dental, and optical lines.
• Provide case management and track referrals to ensure timely care within authorization timelines.
• Coordinate care with GTB Health Services clinics and external vendors.
• Enter and maintain client contracts in the RPMS system for national credit tracking.
• Determine client eligibility for enrollment in the FCP Gateway program.
• Audit and approve billing vouchers; ensure proper expenditure classification.
• Prepare monthly metrics reports for program compliance.
• Screen clients for alternate resources and manage Tribal Premium Sponsorship eligibility.
• Respond to client inquiries regarding eligibility, claims status, and PRC rules.

Skills

Communication skills

Customer service

Computer literacy

Education

High School diploma or GED

Post‑secondary education in business or health fields

Tools

RPMS

FCP Gateway

Job description

• Closes 14-Oct-2026 (EST)
• Department - Health Services
• Suttons Bay, MI, USA
• 20.31 per hour Range start
• Hourly
• Full Time
• Peshawbestown, MI
• Major Medical, Dental, and Prescription, Vision, Life Insurance, 401(k) Plan, PTO, Holidays, Short and Long-Term Disability Coverage, AFLAC

SUMMARY Assist in the administration and coordination of the Purchased/Referred Care Services Self-Governance Compact Health files, computerized FCP Gateway management system, Resource Patient Management System (RPMS), software systems relevant to position as needed, and act as liaison between clients, providers, and Third-Party Administrator. This position will be assigned to 3 counties of our GTB 6 County Service Area as a representative you will be responsible for all claims status, eligibility and customer service to create a well-rounded, efficient department. In addition, this position will include Tribal Premium Sponsorship Program responsibilities. Excellent customer service a must.

MINIMUM QUALIFICATIONS

• Must have a High School diploma or GED.
• Minimum of one-year post high school education in Business Administration or health related fields, or demonstrated experience understanding coordination of benefits.
• Equivalent experience may be considered in lieu of education*

ESSENTIAL DUTIES AND RESPONSIBILITIES

• FCP Portal & Systems Management: Maintain the FCP Gateway and the computerized Voucher Management System, including client, vendor, budget, and commitment files. Utilize the FCP portal daily to manage third-party insurances, establish primary/secondary payer rules, and execute Coordination of Benefits (COB) to maximize alternate resources.
• PRC Prior Authorizations & Thresholds: Review, process, and issue prior authorizations for Purchased/Referred Care (PRC) across medical, dental, and optical service lines. Ensure all approvals strictly align with established medical priority criteria and specific approved tribal/IHS dollar thresholds before routing to the accounting department.
• Case Management & Continuum of Care: Provide proactive case management for PRC clients by tracking referrals, monitoring ongoing care plans, and identifying barriers to healthcare access. Conduct follow-ups on complex medical cases to ensure care is delivered efficiently within approved authorization timelines.
• GTB Direct Services Coordination: Collaborate directly with Grand Traverse Band (GTB) Health Services internal clinics, providers, and clinical staff to coordinate care. Facilitate smooth transitions when patients move between internal direct care services and external specialty vendors.
• Data Entry & Tribal Tracking: Access the FCP Gateway computer system to add, change, and delete client contracts. Input and maintain clean data files within the IHS-provided RPMS computer system to ensure the Tribe receives proper credit for client contacts at the national level.
• Eligibility Determination & Intake: Determine client eligibility for enrollment in the FCP Gateway program by collecting and verifying required income, residency, and tribal documentation. Work closely with Central Patient Registration to streamline intake workflows.
• Financial Voucher Processing: Adjust, audit, and approve billing vouchers for payment. Ensure proper classification of expenditures to maintain the computerized commitment register and submit finalized payment approvals to accounting.
• Comprehensive Metrics Reporting: Track, compile, and analyze prior authorization volumes, expenditure trends, and deferred services. Assist in preparing the monthly report package for submission to the IHS Compact to ensure program compliance.
• Benefits & Premium Sponsorship: Collaborate with the Benefits Coordinator to screen clients for alternate resources like Medicaid and Medicare. Assist with applications, manage the Tribal Premium Sponsorship Program eligibility, and maintain active Certified Assistor status via the CMS Marketplace Learning Management System (MLMS).
• Client Advocacy & Inquiry Response: Serve as a dedicated tribal member advocate with area hospitals and outside providers. Answer written and telephone inquiries regarding eligibility, claims status, and PRC coverage rules.
• Claims Research & Troubleshooting: Investigate and resolve complex claims and eligibility issues for clients, vendors, and providers. Cross-reference historical data utilizing the FCP Gateway, RPMS, and paper files.
• Strict HIPAA Compliance & Confidentiality: Maintain absolute patient confidentiality under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and tribal privacy laws. Secure all Protected Health Information (PHI) across electronic systems (RPMS, FCP Portal) and physical files, and complete annual compliance training.
• Administration & Committee Support: Maintain manual and digital files of check copies, vouchers, and contracts. Attend Tribal Council or Health Committee meetings as requested to provide program data, and perform general customer service tasks like phone support and reception

OTHER SKILLS AND ABILITIES

• Must have good oral and written communication skills
• Must be self-starter and have excellent organizational skills
• Work requires proficiency in computer literacy, preferably in Microsoft Windows, Word, Excel, Outlook, and other Microsoft office products and database applications.
• Must have good interpersonal skills with demonstrated patience, tact, and respect.
• Uses good judgment in interpreting guidelines, in adapting department procedures, or in recommending approaches or solutions for specific problems
• Must have outstanding verbal and written communication skills.
• Must have good time management and organizational skills
• Excellent interpersonal skills with demonstrated patience, tact, and respect.
• Ability to work independently, with people in a group setting, and be a team player.
• Exceptional detail and follow-up skills are critical.
• Must have good customer service skills.
• Must be reliable and maintain confidentiality.

EDUCATION and/or EXPERIENCE

• Must have a High School diploma or GED.
• Minimum of one-year post high school education in Business Administration or health related fields.
• Equivalent experience may be considered in lieu of education.*

DRIVING REQUIREMENTS

None

SUPERVISORY RESPONSIBILITIES

None

EQUIPMENT TO BE USED

General office equipment including but not limited to computer, copier, calculator, fax machine, and telephone.

TYPICAL PHYSICAL DEMANDS

Requires sitting, lifting, reaching and walking. Some lifting of small office equipment up to 25 lbs. Also requires manual dexterity to operate office equipment.

TYPICAL MENTAL DEMANDS

The employee uses judgment in identifying and selecting the most appropriate procedures to use, or in determining which of several established alternatives to use. Deadlines are involved so there is time pressure on occasion.

WORKING CONDITIONS

A good deal of work is performed in an office setting.

COMMENTS

Native American preference will apply. Must be willing and able to pass a background investigation and a drug and alcohol urinalysis as a condition of employment. Adherence to strict company policy in regard to confidentiality is a must.

The above statements are intended to describe the general nature and level of work performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Management retains the right to add or to change the duties of the position at any time through approved motion by Tribal Council. * Any qualifications to be considered as equivalents in lieu of stated minimums require prior approval of the Director of Human Resources.