PRC Lead Specialist

POSITION SUMMARY: Position serves primarily as contract health lead specialist of the contract health program for referral care at the Elbowoods Memorial Health Center, with supervision from the Purchased & Referred Care Manager. Purpose of work is to assure maximum utilization of Contract Health funds by a Comprehensive PRC eligibility determination and use of all available alternate resources and to assist in the claims and payment process for the service units with the care provided away from a direct care facility.

RESPONSIBILITIES AND DUTIES:.

1. All requests for PRC payments a PRC referral must be initiated by using the automated Referred Care Information System (RCIS) this includes: referrals treated at the Elbowoods Memorial Health Center and referred out by a physician, ER services, and IP admissions that are requested for payment.

2. Ensure PRC referrals meet the requirements according to the Aberdeen Area HIS/PRC Medical Priorities.

3. Administers the daily activities required of the PRC approved services by initiating PRC medical purchase orders.

4. Issues denial letters for care that is denied payment by the Tribe.

5. Works with the EMHC medical staff in providing appropriate data for the CHS/PRC requirements for physician, hospital, laboratory, radiology, ambulance and other health services.

6. Liaison functions with patients and providers on the PRC Program.

7. Appointments are scheduled by the PRC Staff for the patients that are referred out for services that are not available at EMHC.

8. Maintains the PRC automated commitment register in the EHR to ensure the accurate accountability of funds and proper fiscal coding procedures.

9. Determines if patient meets residence requirements, notification requirements, medical priority and use of alternate resource.

10. Administers Purchased & Referred Care referral systems for individual patients including coordination of approval system and records management.

11. Performs PRC billing that optimizes funds spent and managed according to I.H.S rules and guidelines, yet assertive manner when assisting patients.

12. Updates accounts receivable database with new claims, cross reference with patient bills that were dropped off.

13. Maintain required reporting as assigned.

14. Work in accordance with all applicable Indian Health Service rules and regulations, AAAHC, compliance with billing standards, and other pertinent regulatory agencies.

15. Assure compliance with standard of accuracy, timeliness, completeness, confidentiality of electronic and hardcopy data.

16. Represents EMHC in a highly professional manner.

17. Establishes positive communications with all departments of EMHC to assure stable operations.

18. Ability to cross-train to other employees within the PRC Department.

19. Demonstrates respect and understanding of confidentiality for patients, staff and others according to policy and HIPAA regulation.

20. Participates in EMHC staff meetings and other meetings as instructed or deemed necessary.

21. Actively strives to educate the community on the mission, vision and values of EMHC in a positive approach to assist in the growth of the organization and assist our community in its healthcare needs.

22. And other duties as assigned.

QUALIFICATIONS, EXPERIENCE, EDUCATION

• High School diploma/GED, REQUIRED. Must submit copy of degree or transcripts with application.
• Associate of Arts Degree in Business Administration or related field. PREFERRED. Must submit copy of degree or transcripts with application.
• Experience and knowledge working with IHS Purchased & Referred Care systems, REQUIRED.
• Thorough knowledge of basic and established procedures related to routine and repetitive aspects of PRC support work, basic medical terminology, forms or reports, respond to routine questions, or perform similar duties.
• Knowledge of basic correspondence methods to assist with correspondence to patients, health care providers and other agencies regarding eligibility, IHS policy and regulation, including letter of denial of claims. Insures confidentiality of patient information.
• Efficient organizational skill and successful completion of tasks under continuing pressure, to meet the deadlines.
• Must be able to interact positively with co-workers, follow instructions, and handle sensitive situation with tact.
• Ability to handle routine tasks daily.
• Computer and equipment knowledge and proficiency, REQUIRED.
• Must be responsible, dependable, and punctual.
• Familiarity with MHA Nation culture, values, and traditions, HELPFUL.
• Must be responsible, dependable, and able to maintain confidentiality of information.
• Must have an acceptable motor vehicle record. A copy of driver’s license and verification of driver’s record from the North Dakota Department of Motor Vehicle, REQUIRED.
• Must submit and clear Criminal Records Background Check.
• Must submit to an Alcohol/Drug Screen and random testing as per policy.
• Indian Preference will apply. Must submit documentation with application to qualify for Indian Preference.
• Veterans Preference will apply. Must submit documentation with application to qualify for Indian Preference.

PHYSICAL DEMANDS/WORK CONDITIONS

• The work requires regular and recurrent standing to perform tasks, walking between the different sections of the facilities, and reaching and bending to obtain supplies and operate systems.

SUPERVISORY REQUIREMENTS:

• The requirement for managing others does exist.

WORKING CONDITIONS:

• Assist the PRC Staff in managing all physical resources necessary for the safe, effective and efficient operation.
• Work is performed in an office environment with varying conditions of noise level, temperature, and illumination.

• Requires prolonged sitting.
• Occasionally lifts up to 25 pounds of material.
• Requires eye-hand coordination and manual dexterity sufficient to operate keyboard, computer and other office equipment.
• Work situations may be stressful and require irregular hours.
• Travel required.
• Potential exposure to blood and other hazardous material, communicable diseases, and other conditions common in a health care environment.

ACKNOWLEDGEMENT

This job description is intended to provide an overview of the requirements of the position. It is not necessarily inclusive, and the job may require other essential and/or non-essential functions, tasks, duties, or responsibilities not listed herein. Management reserves the sole right to add, modify, or exclude any essential or non-essential requirement at any time with or without notice. Nothing in this job description, or by the completion of any requirement of the job by the employee, is intended to create a contract of employment of any type.