Purchased Referred Care Agent at Washoe Tribe of Nevada and California

Gardnerville Ranchos, Nevada, United States -

Full Time

Start Date

Immediate

Expiry Date

21 Apr, 26

Salary

31.59

Posted On

21 Jan, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medical Authorizations, Patient Eligibility, Referral Coordination, Fiscal Management, Quality Assurance, Communication, Confidentiality, Records Management, Insurance Benefits, Technical Assistance, Scheduling, Customer Service, Data Entry, Problem Solving, Interpersonal Skills, Office Software Proficiency

Industry

Non-profit Organizations

Description

Description POSITION TITLE: Purchased Referred Care Agent CLASSIFICATION: Non-Exempt DEPARTMENT: Tribal Health SUPERVISOR: Purchased/Referred Care Manager GRADE: NE11 $21.07 ($43,825.60) - $31.59 ($65,707.20) Position Summary: Under direct supervision the Purchased Referred Care Agent is responsible for initiating medical authorizations and documents that are reviewed for patient information and clinical/fiscal data. Maintains confidentiality of all privileged information. Essential Duties & Responsibilities: · Determines patient eligibility for care under the Contract Health Services Program in accordance with the Code of Federal Regulations “42 CFR, Part 36 § 36.23”. · Identifies and refers patients that are potentially eligible for alternate resources to the Benefits Coordinator. · Educates patient on CHS eligibility requirements and program limitations. · Determines the priority for services provided under the CHS Program based upon established IHS priority guidelines. · Processes medical, mental health, optometry and dental referrals through RPMS/RCIS. · Ensures patients are referred to providers within their PPO/HMO network and utilizes CHS contract providers. · Commits CHS funds by processing purchase order in the CHS commitment register to ensure the accurate accountability of funds and proper fiscal coding procedures. · Closely monitors CHS obligations and expenditures with the objective of keeping within the monthly budget allowance. · Prepares denials based on applicable CHS regulations. · Monitors activities and records pertaining to the fiscal management of CHS funds. · Identifies and refers possible Catastrophic Health Emergency Fund “CHEF” and Third Party Liability Cases to the Fiscal Intermediary department. · Notifies the provider as to alternate resource(s) available to the patient to enable the provider to submit the claim to the appropriate alternate resources. · Reviews Emergency Room notification for CHS eligibility, notification requirements, priority and coordination of benefits and to estimate associated costs. · Participates in Quality Assurance and Utilization Reviews during the CHS Managed Care Committee Meetings. · Interfaces with in-house and outside providers to coordinate appointments. · Interfaces with patients to discuss details of referral and coordinate appointments. · Schedules patient appointments with outside providers. · Coordinates transportation request with the transportation department. · Ensures that pertinent medical information is forwarded to provider or facility prior to scheduled appointment. · Maintains an efficient and effective filing system. · Provides technical assistance to management. · Explains and interprets regulations and policies to ensure appropriate use of CHS. · Develops and implements CHS procedural guides, complies and interprets various alternate resources, references and guides. · Answers telephone and personal inquiries regarding CHS eligibility. · Compiles information and prepares for submission of periodic and special reports concerning CHS to the Business Office Manager. · Performs other duties as required. Requirements Minimum Qualifications: · High School Diploma or GED and two years experience in a medical office setting; or equivalent combination of education and experience. · Must be able to successfully pass a pre-employment drug/alcohol screen and background investigation. · Preference will be given to qualified Native American Indians. Knowledge, Abilities, Skills, and Certifications: · Knowledge of modern office practices, procedures, and equipment. · Knowledge of business English, proper spelling, grammar, punctuation, and basic arithmetic. · Knowledge of records management and basic accounting procedures. · Knowledge of various insurance benefits and contract health service requirements. · Ability to listen intently and skill in working with Native Americans, their families and others. · Ability to communicate effectively in the English language both verbally and in writing. · Ability to establish and maintain professional relationships with individuals of varying social and cultural backgrounds and with co-workers at all levels. · Ability to represent the organization in a professional manner, building respect and confidence. · Ability to maintain confidentiality. · Ability to handle multiple tasks and meet deadlines. · Ability to carry out instructions furnished in verbal or written format. · Ability to work independently with minimal supervision. · Ability to demonstrate excellence in everything, and continually seek improvement in results. · Skill in obtaining exact and precise information from in-depth interviews with Native American patients and other family members to determine possible eligibility for alternate resource funding(s). · Skill in operating business computers and office machines, including in a Windows environment, specifically Word, Excel, Access, and presentation software (such as PowerPoint). Physical Demands: While performing the duties of this job, the employee regularly is required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee frequently is required to walk. The employee occasionally is required to stand; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Work Environment: Work is generally performed in an office setting with a moderate noise level. The Washoe Tribe of Nevada & California requires a background check of each new hire for employment purposes. Therefore, all conditionally offered positions will be subject to the following: · Negative alcohol and drug screen · Meet requirements of Public Law 101-630 · Obtain or possess a valid driver’s license for either the state of Nevada or California within 30 days · Must be insurable under the Washoe Tribe’s driving policy

Responsibilities

The Purchased Referred Care Agent is responsible for initiating medical authorizations and ensuring patient eligibility for care under the Contract Health Services Program. They also coordinate referrals, manage fiscal responsibilities, and educate patients on program requirements.