To perform the job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge skill and/or ability required.
This individual is responsible for providing support and technical assistance in the management and administration of the Purchased Referred Care (PRC) program.
- Determines patient eligibility for care under the PRC program
- Determines the priority for services provided under the PRC program
- Researches potential CHEF cases to collect documentation, prepares and submits CHEF cases to Area Office. Maintains files for the CHEF Case Management Program
- Monitors that automated denials system to ensure all denials are entered
- Manage denial package for non-referrals or no alternate resources
- Administers the day-to-day activities required of the PRC program by initiating PRC purchase orders.
- Retrieve and sort incoming PRC mail
- Research claims received from providers to determine eligibility and alternate resources
- Review patient’s visits and appointments to verify insurance information
- Communication with providers related to patients with no alternate resources
- Review bills from patients and creates purchase orders as necessary
- Work closely with Benefits Coordinator and other staff to assure prompt processing of alternate resources
- Reviews the bi-monthly referrals report from WebTPA. Works with the referrals coordinator to issue referrals needed
- Answer phone calls related to the PRC program and/or claims status inquires
- Utilize the WbTPA (iii:PUT) system to check on claims status. Communicate as necessary
- Creates a tracking and following-up system on process related to the PRC program
- Develops and implements FMIHC policies and procedures. Guidelines, and operating instructions, and maintains reference files on all Purchased Referred Care
- Explain and interprets regulations and policies to health service providers and recipients, as well as FMIT personnel
- Good Communication skills and the ability to deal with patients and families during potentially stressful times
- Maintain strict patient confidentiality following state and federal laws
- Performs other duties assigned by manager
- High school graduate or GED equivalent
- Three (3) years previous experience handling referrals and/or processing claims preferred.
- Experience working in a medical office.
- Previous electronic medical record experience required.
- Must be organized and able to manage multiple tasks in stressful situations
- Good computer and phone skills
- Good critical thinking skills that allows for quick assessment of patient needs
Certificates and Licenses:
- Able to sit for extended periods of time
The Indian Preference Act will be enforced. The above statements are intended to describe the general nature and level of the work being performed by people assigned to this work. This is not an exhaustive list of all duties and responsibilities associated with it. The Fort Mojave Indian Tribe reserves the right to amend and change responsibilities to meet business and organizational needs.