Purchased/Referred Care (PRC) & Referrals Specialist

Southern Indian Health Council, Inc; Alpine (CA); On-site; USD 29,000 - 42,000; Full time

Job summary

Southern Indian Health Council, Inc. in Alpine, CA is seeking a PRC & Referrals Specialist to initiate and track referrals for medical, dental, and behavioral health services.

You will coordinate with providers, ensure pre-certification and appointment adherence, and update referral records across departments. The role requires a high school diploma or GED, at least two years of medical office experience, and excellent customer service and organizational skills.

Qualifications

• Must possess a High School diploma or GED certificate.
• Must have Two years of medical office experience.
• Knowledge of Healthcare Insurance authorization requirements and systems.
• Medical Assistant certification and experience preferred.
• Must have 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.

Responsibilities

• Initiates referral process for all patients referred by SIHC providers to healthcare specialty providers for medical, dental, and behavioral health services.
• Assists in resolving pre-certification, registration, and case management concerns prior to patients' appointments.
• Tracks the progress of all referrals to ensure that referral appointments are kept.
• Works cooperatively with Medical, Dental, behavioral health, and Health Information Management Department to maintain updated records of all referrals.
• Maintains and updates SIHC referral tracking system.
• Works 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.
• Position will provide referral services for both Alpine and Campo clinics for Medical, Dental, and Behavioral Health.

Skills

Customer service

Medical office coordination

Communication

Organization

Education

High School diploma or GED

Two years medical office experience

Medical Assistant certification (preferred)

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Purchased/Referred Care (PRC) & Referrals Specialist

Full Time Alpine, CA, US

Salary Range: $21.00 To $30.21 Hourly

Job Announcement

Position Title: Purchased Referred Care (PRC) & Referrals Specialist

Department: Health Information Management

Supervised By:Health Information Management Director

Location: Alpine/Campo

Status:Non - Exempt

Closing Date: TBD

Compensation:$21.00 - $30.21/hr. - DOE

Grant: N/A

Hours: Full time, Monday-Friday, 8:00AM-4:30PM.

GENERAL STATEMENT OF RESPONSIBILITIES:

Under the direct supervision of the Health Information Management Director initiates referral process for all patients referred by SIHC providers to healthcare specialty providers for medical, dental, and behavioral health services. Assists in resolving pre-certification, registration, and case management concerns prior to patients' appointments. Tracks the progress of all referrals to ensure that referral appointments are kept. Works cooperatively with Medical, Dental, behavioral health, and Health Information Management Department to maintain updated records of all referrals. Maintains and updates SIHC referral tracking system. Works 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. Position will provide referral services for both Alpine and Campo clinics for Medical, Dental, and Behavioral Health.

SPECIFIC DUTIES AND RESPONSIBILITIES:

• Maintains ongoing tracking appropriate documentation on referrals to promote team awareness and ensure patient safety.
• Review's referral requests generated by primary care physician.
• Updates SIHC referral tracking systems in cooperation with Health Information Management to ensure specialties reports receive in a timely manner Update the information in the referrals tracking system.
• Process assembles and review all medical records information concerning patient's managed care / for appropriate specialty providers.
• Contact the referred entity and insurance companies to ensure prior approval requirements are met. Present necessary medical information such as history, diagnosis and prognosis. Facilitates appointments for patients and requests follow-up information from specialist. Contacts patients if appointment is not kept and assists in rescheduling in a timely .manner
• Educates patient regarding referral guidelines and expectations as well as policies and provides information about location of specialist's office or hospital.
• Reviews rejected requests for procedures or visits and initiates appeal when indicated.
• Ensure that referrals are addressed in a timely manner. Work closely with Patient Advocates and Community Health Representatives to ensure patients will be able to schedule an appointment with the specialty providers
• Remind 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.
• Maintain patient confidentiality, know and adhere to all HIPPA regulations. Mails, faxes, medical records, should be kept confidential and safeguarded at all times.
• Maintain a 10-12 referrals submission daily and ensure the accuracy of documents submitted to specialties' offices.
• Addresses patient problems/concerns as may arise. Provide excellent customer service .
• Answers telephone inquiries on matters relating to referrals.
• Complies with SIHC's policies and procedures Process all Purchased / Referred Care referrals for patients in this program. Assists with maintenance of patient registries to include:
• Determines if clients meet Contract Health Services eligibility requirements for the Purchased and Referred Care program.
• Maintain extensive follow-up system on all Purchased and Referred Care accounts.
• Work directly with various medical, dental, and behavioral health business offices and other clinical providers referred to by Purchased and Referred Care
• Arrange transportation for patient/clients to assist them with obtaining necessary documents when applying for an alternative resource.
• Receive telephone and written inquiries concerning patients admitted to facilities other than IHS facilities. Secure complete data from medical, dental, and behavioral health providers.
• Ensure that the patients SIHC chart is up to date with the 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, third party insurance eligibility determination.
• Enter PRC invoices and claims on the PRC tracking system.
• Educate patients about PRC program eligibility, benefits, and guidelines
• Assist patients in understanding their rights and responsibilities within the program
• Develop and maintain patient education materials and resources
• Stay 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

QUALIFICATIONS:

Education/Experience: Must possess a High School diploma or GED certificate. Must have Two years of medical office experience. Knowledge of Healthcare Insurance authorization requirements and systems. Medical Assistant certification and experience preferred. Must have 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. Education, training or experience which complements knowledge and skills stated above is desirable but does not substitute for minimum requirements as stated

Licenses/Certifications: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.

Character: Applicants must have a 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.

Skills: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, resolves conflicts, negotiates situations, and facilitates consensus.

Physical and Personal Requirements: 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.

Compliance: 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.

Other: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.

INDIAN PREFERENCE:

INDIAN PREFERENCE: In the filling of any SIHC job vacancy, preference may be given to qualified Native American Indians, pursuant to the Indian Preference Hiring Act, 25 USC 472, unless other laws require the filling of a vacancy without regard to Indian preference (e.g. Public Law (P.L.) 94-437, "Indian Health Care Improvement Act (IHCIA)." To receive Indian Tribe ore for any SIHC position, the applicant must be enrolled, or be eligible for enrollment, as an American Indian with their Tribe, or must be certified as an American Indian from the designated Tribal Representative. Applicants claiming Indian preference must attach verification of their claim to the SIHC application, including Certification of form BIA-4432, which is available from the SIHC Human Resources Department. If verification is not or cannot be verified, the applicant will not receive Indian preference for purposes of the interview.