Position Summary

The Purchased Referred Care Specialist (PRC Specialist) will provide services supporting the PRC Department and all functions within to include referrals, claims and alternate resources/patient benefits to qualified individuals in the Pueblo of Sandia health plans. This position provides support services to the Health Center PRC program and all related services in maintaining a viable program that demonstrates compliance with policy and regulations.

Our philosophy is built on the principles of integrity, fairness, collaboration, communication, and recognition for performance excellence. Meeting all performance standards leads to attracting and retaining a qualified workforce, provides opportunities for qualified team members, and contributes towards the ongoing success of the Pueblo of Sandia today and in the future.

Essential Duties and Responsibilities

1. Provides lead support to the front-end of the PRC office patient referral process.
2. Records and organizes patient and referral information for review by the Health Center Director and/or the Business Manager for determination.
3. Verifies eligibility for Sandia PRC services with consideration of factors including, but not limited to, tribal membership, tribal descendent status, patient age, place of residence, availability of alternative resources and student status.
4. Ensures medical priorities are assigned properly.
5. Identifies alternate medical resources available to patients, including but not limited to Medicare, Medicaid, Veterans Administration, Workers Compensation and Patient Assistance Medication Coverage. Prepares additional liability forms as necessary.
6. Coordinates appointments with outside contract provider services or IHS facility and patients including proper documentation and transportation when applicable. Completes and tracks all necessary information in system as appropriate for services.
7. Maintains consistent communication with internal and external staff to ensure appropriate case monitoring and management practices are in place for continuous continuity of care through completion of PRC services.
8. Provides patient support services related to follow-up care, diagnostic testing, and referrals to medical specialists for consultation and/or treatment. Coordinates and schedules single or multiple appointments based on physician availability, the urgency and type of treatment, the required sequebce of tests and imaging and the patient’s travel needs.
9. Provides patients with instructions on required medical preparations prior to treatment. Notifies appropriate staff of scheduled appointments and ensures all necessary medical records and documentation are prepared. Informs patients of required follow-up care as directed by the clinician, including updates regarding cancelled or rescheduled clinics.
10. Performs technical duties involving the review and analysis of medical records to ensure completeness, accuracy, consistency and compliance with applicable requirements. Identifies and refers any discrepancies or inconsistencies – particularly those involving interpretation of medical information or the the relationship between diagnosis and treatment – to the physican for clarification and resolution.
11. Plans and executes office operations addressing issues and deviations in alignment with established procedures, priorities, policies, supervisory directives and program objectives, while adhering to accepted professional practices.
12. Enters daily data into the computer system, including PRC records, notification, referrals, patient information, PRC denials and any other PRC program data required to comply with established guidelines and deadlines.
13. Maintains the privacy and confidentiality of patient information in accordance to the Privacy Act, Health Insurance Portability and Accountability Act (HIPAA), Electronic Health Record (EHR) system policies and procedures.
14. Performs other related duties as assigned by supervisor.

Additional Responsibilities

1. Creates an environment of teamwork though strong communication, mentoring, and providing guidance, support, and appreciation for team members contributions
2. Performs special projects and other job-related duties as assigned.

Key Performance Indicators

This position has Key Performance Indicators (KPI’s) identified as a measurement of success. KPI’s will be shared with all team members who work in this job title and feedback will be provided regarding the successful completion of the KPI’s as part of the performance review process.

Knowledge, Skills, and Abilities

1. Intermediate knowledge of medical terminology preferred. Knowledge of PRC regulations, policies and procedures, third party billing standards policies and procedures to operate the program effectively and efficiently. Intermediate knowledge of computer programs and use.
2. Knowledge of Medicare, Medicaid, Workers Compensation and other health care resources preferred.
3. Strong ability to communicate with tact and diplomacy with diverse groups of people.
4. Strong ability to work on a variety of assignments/issues concurrently within established deadlines.
5. Strong attention to detail with ability to function effectively with frequent interruptions.
6. Strong ability to work and communicate effectively and cooperatively in a service environment, including extensive telephone communication.
7. Strong ability to protect confidential information.

Education and Experience

Required:

1. High School Diploma, GED certification or equivalent
2. One (1) year of hospital, medical office or other health care related experience.
3. One (1) year familiarity with medical terminology, insurance verification and/or purchased referred care process.
4. One (1) year knowledge of UB04, CMS1500, ADA claims forms and explaination of benifits

License/Certifications/Registrations

1. The following license and/or certifications are required within 6 months of employment start date:

• CPR/1st Aid certifications
• PE/MOSAA Certification

1. Must be able to successfully pass a stringent background investigation and character investigation in compliance with PL 101.630.
2. Will require a pre-employment and random drug screening.
3. Must possess and maintain a valid, unrestricted New Mexico Driver’s License.

Physical Requirements/Working Conditions

The following selected physical activities are required to perform the essential functions of this position

Physical Requirement

Description

Balancing

Maintaining body equilibrium to prevent falling and walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.

Crouching

Bending the body downward and forward by bending leg and spine.

Feeling

Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.

Finger Dexterity

Picking, pinching, typing or otherwise working, primarily with fingers rather than with the whole hand as in handling.

Grasping

Applying pressure to an object with the fingers and palm.

Hearing

Perceiving the nature of sounds at normal speaking levels with or without correction. Ability to receive detailed information through oral communication, and to make the discriminations in sound.

Kneeling

Bending legs at knee to come to a rest on knee or knees.

Lifting

Raising objects from a lower to a higher position or moving objects horizontally from position-to-position. This factor is important if it occurs to a considerable degree and requires substantial use of upper extremities and back muscles. (Up to 25 lbs.)

Pulling

Using upper extremities to exert force to draw, haul, or tug objects in a sustained motion. (Up to 25 lbs.)

Pushing

Using upper extremities to press against something with steady force to thrust forward, downward, or outward. (Up to 25 lbs.)

Reaching

Extending hand(s) and arm(s) in any direction.

Seeing

The ability to perceive the nature of objects by the eye.

Walking

Job requirements include, in the performance of duties, walking throughout the work area, on various work surfaces throughout internal or external locations.

Sitting

Particularly for sustained periods of time.

Standing

Particularly for sustained periods of time.

Stooping

Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full motion of the lower extremities and back muscles.

Talking

Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.

List Working Conditions Required:

1. Work is performed indoors.

2. May work extended hours and evening or weekend hours.

3. Subject to hazardous materials which may cause bodily harm: smoke, common colds, influenza, dust, odors and elevated noise levels.

4. Tasks may be performed on uneven, inclined, challenging, soft carpeted floors, cement structures, and surfaces.