PRC Tech

Department:Purchased Referred Care

Reports to:Director of PRC

FLSA Status:Non-Exempt

Type of Position:Full-Time

Revised Date:02/07/2022

MISSION & VISION STATEMENT:

The Kewa Pueblo Health Corporation (KPHC) is established for the purposes of carrying out the vision and mission of the Santo Domingo Health Center (SDHC). The MISSION of KPHC is:  “ENSURING HEALTH & WELLNESS THROUGH EXCELLENCE IN HEALTHCARE WITH RESPECT FOR CULTURE” and the VISION OF KPHC is:  “HEALTHY PEOPLE, HEALTHY COMMUNITY, and HEALTHY LIFESTYLE”.

POSITION PURPOSE:

The purpose of this position is to provide a full range of services related to contract health, business office, medical records, and clinic administration.

PERFOMANCE EXPECTATIONS:

In performance of their respective tasks and duties all employees of the Kewa Pueblo Health Center are expected to conform to the following:

• Uphold all principles of confidentiality and patient care to the fullest extent.
• Adhere to all professional and ethical behavior standards of the healthcare industry.
• Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
• Possess cultural awareness and sensitivity.
• Maintain a current insurable driver’s license.
• Comply with all Kewa Pueblo Health Corporation and Santo Domingo Health Center policies and procedures, as well

ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES:

• Determines patient eligibility for care under the PRC Program. Requires the application of PRC rules and regulations on PRC delivery areas. Determines patient eligibility as a prerequisite to authorization of funds and requires making accurate and independent decisions for the provision or denial of payment for services based upon eligibility criteria.

• Defines alternate resources available to patients under the PRC Program and independently determines patient eligibility for Medicare, Medicaid, Veterans Administration, Medical Services, private insurance, state programs, and any other applicable resource.  Thorough working knowledge of various Third Parties, such as Medicare, Medicaid, Private Insurance, etc., availability of health care resources, rules of eligibility for medical and other available programs to assist in payment of health care costs.  Contacts alternate resource agencies, conducts personal interviews with patient and/or family members to determine potential eligibility for any alternate resources, and works as a liaison between patient and outside provider/ resource regarding follow up care and eligibility of coverage.

• Participates in determinations of reasonableness of rates by non-IHS providers and contractors of PRC by providing appropriate data and other input.

• Performs patient services related to follow-up care, diagnostic procedures, and referrals to medical specialist for consultation and/or treatment. Schedules appointments and /or multiple appointments based on schedules, availability of doctors, nature of treatment and /or emergency, the logical sequence of required tests and x-rays, and the amount of travel time required by the patients.

• Instructs a patient regarding necessary medical preparation prior to receiving treatment. Notifies appropriate personnel of scheduled appointments and of medical records and files required documentation. Notifies patient of medical follow-up as requested by the clinician and for cancelled and /or rescheduled clinics. 

• Disseminate information through proper channels in accordance with established procedures and performs other general clerical tasks necessary in carrying out patient appointment functions.

• Obtains from the patient, proof of tribal enrollment for medical eligibility. Maintains sufficient health records forms, authorizations or clinic information, eligibility forms and standard forms explaining the patient's rights under the Privacy Act.

• Performs technical functions related to the analyzing of medical records for completeness, consistency and compliance with requirements. Refers apparent discrepancies or inconsistencies in the records, which involve questions of interpretation of medical reference of the relationship between diagnosis and treatment to the physician for resolution.

• Maintains a current checking system on each patient receiving medical care from this facility. This consists of contacting various Federal, State and County agencies to verify current eligibility for third party health insurance and their identifying numbers.

• Prepares and compiles the authorization for release of medical information, assignment of benefits and pre-certification. Gathers and compiles information needed to determine benefits or benefits related health care services for all third party billing purposes and processes.

• Searches and retrieves individual patient health record(s) to gather and compile information for outpatient services. Searches and gathers the clinical management of individual patient's condition and diagnosis to generate indicators of health status and health statistics from the ICD-CM coding volumes and CPT coding system.

• Performs daily interviews to obtain specific demographic and insurance information in a diplomatic and confidential manner.

• Plans and carries out the work of the office and handles problems and deviations in accordance with established instructions, priorities, policies, commitments and program goals of the supervisor and accepted practices in the occupation.

• Reviews incoming medical bill from providers to determine if an approved referral was made and if not, collects the necessary data and paperwork for submission to the Health Center Director and IHS PRC staff for approval or denial.

• Inputs daily into the computer systems PRC data, notification information, referral information, patient information, PRC denial information and any other appropriate PRC program data necessary to meet established mandatory guidelines and deadlines.

• Provide technical PRC information and guidance on all inquiries. Ensures prompt follow up with appropriate personnel and vendors maintaining strict confidentiality.

• Answers telephone and personal inquiries regarding payment, outstanding charges, eligibility, etc.  Answers routine correspondence and compiles information and assist in the preparation of periodic and special reports concerning contract services to Area Office and Health Center Director.

• Prepares routine correspondence when appropriate to patients and providers.

• Enhances professional growth and development through participation in educational programs, meetings, and workshops.

• Performs other related duties as assigned by supervisor.

MINIMUM MANDATORY QUALIFICATIONS:

Education:

• High School Diploma or GED equivalent

Experience:

• Two or more years’ experience in duties and responsibilities specified.

Knowledge, Skills, Abilities and Other Qualifications:

•          Knowledge of procedures and regulations covering the processing of a wide range of documents under the Purchase Referred Care (PRC) Program, knowledge to process data from a variety of forms, documents, and reports (e.g. medical authorizations, DCR’s and accounting records). Knowledge of PRC funding limitations and policies to advise others of procedural and regulatory requirements, total program, operation, priorities and goals of the alternative resources program, ability to keep abreast of current changes in policies, regulations of eligibility, medical terminology and diagnostic and financial coding, ability to participate in planning, implementation and improvements of the alternate resources, knowledge of established procedures, required forms, etc. associated with the various health insurance programs. Knowledge of the nature and contents of publications, forms, and other guidelines or information material pertinent to carrying out or coordination work and specific program activities. Knowledge of computer word processing and use of appropriate software package.

PREFERRED QUALIFICATIONS:

• Associate’s Degree in a related field
• Understanding of medical terminology.
• Bilingual skills in English and the Keres native language.
• Prior experience working with Indian Health Services (IHS), a Tribe or Tribal Organization.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. This position may be exposed to certain health risks that are inherent when working within a health center facility.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the primary functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk and hear. There may be prolonged periods of sitting, keyboarding, and reading. The employee must occasionally lift and/or move up to 50 pounds.

MENTAL DEMANDS:

There are a number of deadlines associated with this position. The employee must also multi-task and interact with a wider variety of people on various and, at times, complicated issues. 

OTHER:

All employees must uphold all principles of confidentiality and patient care to the fullest extent. This position has access to sensitive information and a breach of these principles will be grounds for immediate termination.

Disclaimer:  The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position.  It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed.

Salary Range:  $20.56 - $30.84