Purpose
The PRC Health System Specialist provides strategic, administrative, and operational leadership for Trenton Community Clinic’s (TCC) Purchased and Referred Care (PRC) program, ensuring eligible patients receive timely, culturally responsive access to medically necessary services not available within TCC. This position ensures compliance with federal regulations Tribal policies, and funding requirements while promoting program efficiency, fiscal stewardship and high-quality patient experience. Performs difficult and complex assignments that encompass a variety of program activities, assisting in program development, management, operation, evaluation and annual budget planning of the comprehensive PRC program. Oversee all daily operations, including eligibility determination, medical priority review, authorization processes, case management oversight, and vendor relations. Maintains responsibility for budget oversight, expenditure monitoring, and the development and implementation of program policies and procedures. Adheres to strict HIPAA and confidentiality requirements. Honors and represents the mission, vision and values of the Trenton Indian Service Area (TISA) and the TCC.
Responsibilities
Promotes an organizational culture that embraces the values of respect, caring, support, effective communication, teamwork, collaboration, accountability, and responsibility; and works with all staff to create and maintain a workplace environment reflective of such values
· Ensures PRC program operates in accordance with the applicable federal guidelines and laws
· Conducts regular audits of member eligibility under the provisions of Tribal and/or federal rules.
· Monitors all sever health care claims that may meet the spending levels and qualify for the Catastrophic Health Emergency Fund (CHEF)
· Serves as the liaison between the Indian Health Service (IHS) and the TCC for CHEF Claims
· Keeps leadership and other departments informed of the status of program by attending meetings and submitting reports to Executive Leadership and IHS as required.
· Reviews of medical claims to ensure that claims are paid at Medicare-Like rates
· Assist in referring eligible patients for necessary contract health services
· Document all referrals and follow-up in the EHR RCIS system
· Authorizes medical, dental and vision services for eligible medical health systems or other IHS which is preferred
· Maintain a current referral commitment register which requires the accurate accountability of funds which include expenditures and inform the THD of the status of funded clinic commitments on a regular basis and to the Area Office on an annual basis
· Present ER admission notes, hospitalizations and referrals in weekly PRC meetings with provider staff and THD and confirm eligibility for PRC services. Verifies all ER admission notifications, invoices of private vendors, logs all Approval, Denials and Deferrals during daily PRC Meetings. Notating Approval, Denial and Deferrals.
· Prepares third party report forms for the recovery of the cost of hospital and professional services furnished to federal beneficiaries whose injuries resulted from negligent third persons, such as a MVA (motor vehicle accident)
· Obtains information via telephone or personal inquiries on the status of patient billing; i.e., charges, payments, and outstanding balances
· Incumbent receives visits and telephone calls from hospital personnel, patients, and private vendors regarding admissions to outside facilities (72-hour notice). Will always maintain professional telephone etiquette in all contacts with hospital personnel, patients, and private vendors
· Assist, when necessary, in arranging appointments, application of alternate resources for patients
· Prepare denial and deferral letters to patients and any ineligible patients
· Is TCC liaison to vendors and through written correspondence explains regulation and policies to health service vendors. Demonstrates the utmost diplomacy and tact while providing excellent customer service
· Verify the completeness and accuracy of invoices and supplementary documents returned for payment
· Adheres to, and upholds HIPAA regulations, requirements, and training
· Additional responsibilities may be assigned as appropriate, this summary is not considered to encompass all responsibilities
Physical Demands
· Regularly required to sit, stand and utilize fine motor skills with computer input, excellent visual acuity is required
· Filing and cycling file cabinets every 3 years for storage
· Must be willing to travel as needed and requested
Qualifications
· High school diploma or GED equivalent
· Preferably five (5) years of experience working in an administrative support role or healthcare business office, sufficient to understand and perform the responsibilities of the position
· Knowledge of basic accounting methods to assist with monthly reports
· Must be able to type from a set format with minimal errors; utilize excel spreadsheets, other Microsoft Office applications
· Ability to demonstrate excellent observation, problem solving, verbal and written communication skills
· Ability to utilize electronic health record systems, related applications and computer systems, software, phone systems and other standard office equipment
· Must be detailed oriented and demonstrate strong organizational and interpersonal skills
· Valid driver’s license with acceptable motor vehicle record
· Demonstrate awareness, sensitivity, and appreciation of Native American culture, traditions, customs and needs
· Ability to successfully pass all pre-employment requirements including a drug/alcohol test and background investigation
· Ability to successfully pass all pre-employment requirements including a drug/alcohol test and background investigation
Pay: $18.00 - $22.00 per hour
Benefits:
- 401(k) matching
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Work Location: In person
