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Form of workJob Purpose & Position Overview
Greets visitors and answers incoming calls for the Purchase Referred department. Verifies purchase referred care eligibility for the Native American patients using Federal PRC (Purchase Referred Care) regulatory criteria and also determines patient eligibility for third-party alternate resources. Initiates medical authorizations to include hospitalization and professional fees for eligible patients. Conducts on-site patient interviews to establish eligibility and completes and maintains application for medical care. Schedules medical appointments for patients with various hospitals and specialty clinics. Reviews incoming referrals to determine if authorizations have been issued.
Specific Job Duties/Responsibilities:
Demonstrates the Winnebago Tribe’s core mission, vision, and values.
Apply all PRC rules and regulations on PRC Delivery Areas, geographical facility proximity, tribal membership, and residence.
Determines patient eligibility for alternate resources available under the Purchased Referred Care Program for Medicare, Medicaid, Vocational rehabilitation, V.A., private insurance or other third parties.
Coordinates patient’s scheduled appointments, performs clerical duties related to patient referrals, transfers, admissions, and discharges.
Participates and assist with running a PRC referral report, develop a referral excel spread sheet to submit and review in the M, W, F PRC Committee with the PRC Case Manager and medical staff.
Responsible for keeping an updated PRC patient referral tracking log.
Collaborates with all WCHS staff to obtain required information to schedule patient appointments such as: outside orders, and required outside vendor forms are attached and completed.
Completing all call-in referrals communicated by the patient in a timely manner.
Performs periodic reviews and audits authorization for payment for conformity to policy and regulations.
Administers day to day activities required of the PRC program and insures that authorizations for payment are processed and comply with established priority of services.
Provides all authorizations for payment and patient third party resource to the specialty clinics, hospitals, and all other vendors identified within each patient referral.
Insures patient transportation arrangements are entered into Moonwalk and collaborates with WCHS Medical Service Department for transportation services.
Maintains denial correspondence including supporting documentation and insures that reconsideration requests are made available to the appropriate supervisor in a timely manner.
Ability to communicate both orally, or in writing.
Has open and respectful communication with patients, outside providers, and WCHS hospital providers and staff.
Maintains a high ethical standards and conduct; and protects the organization by keeping the patient’s information confidential.
Duties listed are only an illustration of the various types of work performed. The omission of specific duties does not exclude them from the position if the work is similar and related.
Qualifications/Skills:
High School Diploma or Equivalency and 2 years of experience in a healthcare setting.
Practical knowledge of specialized medical terminology preferred.
Must possess computer experience relevant to duties of the position.
Incumbent will receive training on the Privacy Act and the use of confidential information and health records.
Must possess computer skills that include Microsoft Office Excel, Word, Outlook, Publisher and PowerPoint.
Must possess an understanding of the Electronic Health Record and RPMS Systems used by the I.H.S to document patient care.
Knowledge of all Tribal Health Programs and Health Care experience is preferred.
Must perform all duties in a manner that ensures the strictest confidentiality due to access to sensitive information.
Must maintain a positive and professional attitude with the ability to effectively handle tasks, situations and clients with tact, courtesy, respect, and objectivity.
Must recurrently employ moral and ethical judgments.
Must have excellent communication skills.
Must keep accurate daily, weekly and monthly reports.
Training Requirements:
Health Streams, RPMS, EHR, HIPPA/Privacy Act, ISSA, Annual Fire Extinguisher, and others as assigned.
Physical Requirements:
Normal to light office work which includes the ability to lift up to 10 lbs.
Regularly required to walk, stand, and sit for extended periods of time and use hands to operate computer keyboard, phone, and various office equipment.
Cognitive Requirements:
Reading, writing, calculating.
Excellent social interaction skills.
Reasoning/Analysis
Ability to work effectively both independently and as a team.
Works with minimal to no supervision.
Language Requirements:
Must possess the ability to read, write, and speak the English language fluently.
Must be able to continually and effectively employ professional verbal and written communication skills.
Certificates, Licenses & Registrations:
All applicants will comply with 45 CFR 1301, Subpart D, Section 1301.31, C and D, which require all prospective employees to sign a declaration prior to employment regarding all arrests and convictions of child abuse or violent felonies and to comply with PL 101-630 and PL 101-637 regarding criminal records check.
WCHS is an equal opportunity employer. Employment practices are free of discrimination. As provided by Federal Law, all qualified Native American applicants shall receive preference over Non-Native American applicants. In the absence of qualified Native American applicants, consideration will be given to all other applicants without regard to race, color, religion, sex, sexual orientation, national origin, age, marital status, veteran status, genetic information, disability or any other reason prohibited by law in provision of employment opportunities and benefits.
Please note the position description duties, responsibilities, and activities may change at any time with or without notice.
