Under general supervision of the Purchased Referred Care (PRC) Nurse Manager, the Referral Coordinator assures PRC fiscal accountability working closely with various departments to ensure coordination between the referring PCP and specialist. Responsible for determining PRC eligibility and coordinating specialty medical service for Dilkon Medical Center (DMC) and Winslow Indian Health Care Center (WIHCC) when WIHCC is unable to meet these healthcare needs. Participates and follows PRC policy and guidelines to meet program goals. Upholds the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.
This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.
Essential Duties & Responsibilities:
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Maintains regular attendance and punctuality.
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Greets visitors, patients, families, staff and physicians. Uses appropriate, professional courtesy for all telephone interactions.
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Screens all cases for Purchased Referred Care eligibility.
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Ensures that all eligibility factors are met prior to obligating PRC funds.
- Obtains necessary medical information for the RN Case Manager or Clinical Director (CD) to determine medical priority.
- Makes timely decision to approve or deny a referred request.
- Monitors progress in improving the referral billing and claim process to close-out open PO’s.
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Assists patients and families in understanding eligibility and program limitations; documents patient education.
- Confirms and is responsible outside consults are faxed for review and scheduling based on medical priority as 1-7 day, 8-30 day and non-urgent referrals.
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Refers patients to Patient Benefits Coordinator (PBC) to apply for alternate resources when they are potentially eligible and documents efforts.
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Promotes fiscally responsible use of the referral system advocating IHS referrals first for patients without alternate resources, contract vendors next, and open market last.
- Monitors contract health obligation and expenditure rates with the objective of staying within the funding perimeters.
- Uses the Disclosure Statement Report for obligating by Diagnostic Rate Grouping (DRG) where possible.
- Maintains familiarity with the contracts or rate quotes of frequently used vendors.
- Provides reports as required by the HSS or PRC Supervisor (backlog report).
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Keeps track of denials for potential AHCCCS eligible and affirms or reverses based on DES decision.
- Responsible for all referrals ensuring they entered accurately into the Referred Care Information System (RCIS) and Electronic Health Record (EHR).
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Verifies that every purchase order is linked to an episode of care, confirms decision of payment is accurate and all denial reasons reflect quality documentation and timeliness.
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Ensures accurate data entry in order to obtain meaningful reports.
- Teaches and trains employees; evaluates program performance, and training needs.
- Reports any high-risk cases or barriers to care to the RN Case Manager.
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Maintains registers of select groups of patients to ensure alternate resources are maximized, patients are not lost to follow up, and that appropriate vendors receive payment (e.g. dialysis, oxygen, PAP rentals).
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Responsible for entering reoccurring obligations, timely, accurately and without reminder.
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Requires completion of tasks or duties assigned by a supervisor.
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Assists with solving computer software and technical issues that may arise.
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Upholds all principles of confidentiality and patient care to the fullest extent.
- Adheres to all WIHCC General Work Rules and Standards of Ethical Conduct.
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Adheres to all professional and ethical behavior standards of the healthcare industry.
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Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
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Responsible for referral tracking utilizing the PRC referred spreadsheet template.
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Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
- Possesses cultural awareness and sensitivity.
- Maintains compliance with all Human Resources requirements.
- Responsible to comply with RCIS training and stay current with PRC updates.
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Performs other duties as assigned.
Minimum Qualifications:
Associate’s Degree in Business Administration or related field required. Two years’ experience in an administrative support, billing and purchasing in a health care industry and has demonstrated ability to provide a high level of customer service is required. Bilingual skills in English and Navajo language preferred. Must maintain a valid unrestricted and insurable driver’s license. Must successfully pass a background investigation and maintain suitable requirements for a Child Care position. This position is considered as a Child Care position, which requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).
Knowledge, Skills, Ability:
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Knowledge of PRC programs and regulations; and knowledge of RPMS packages, that is CHS, RCIS, EHR and Patient Registration.
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Knowledge of allotments, objects, sub-object and class coding used in the CHS/MIS system.
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Knowledge of medical terminology and medical care practices and procedures.
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Knowledge of CPT/ICD-10 coding and HCPCS.
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Knowledge of fiscal accountability.
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Knowledge of strong work ethics in the workplace.
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Knowledge of alternate resources: state Medicaid, tribal health programs, Medicare, private insurance other related agencies, programs and procedures, private insurance and Medicare.
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Knowledge of the basic principles of Case Management and Improving Organizational Performance.
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Knowledge of basic application of confidentiality.
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Knowledge of basic computer skills, e.g. Outlook, Word, Excel, PowerPoint.
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Ability to maintain or establish registers of eligible patients in varied programs (e.g. dialysis).
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Ability to understand and comply with the requirements of the Privacy Act, HIPAA, and maintaining confidentiality of patient information.
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Ability and willingness to learn and to share information with others.
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Skill in maintaining records.
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Ability to be dependable in attendance and job performance.
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Ability to meet attendance, overtime (if necessary), and other reliability requirements of the job.
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Ability to accept and learn from feedback.
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Ability to communicate effectively both verbally and in writing.
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Ability to provide exemplary customer service at all times.
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Ability to interact positively with others and possess great interpersonal skills.
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Ability to multitask and perform well under pressure.
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Ability to have self-confidence.
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Ability to be a great team player.
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Ability to accept and learn from supervisor/peer critique.
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Ability to be flexible and adaptable to the changing needs of the organization.
Physical Demands:
While performing the duties of this job, the employee regularly is required to walk; sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee frequently is required to stand; climb or balance; and stoop, kneel, crouch, or crawl. The employee frequently is required to taste or smell. The employee must occasionally lift and/or move up to 25 pounds.
Work Environment:
Work is performed in an office setting or outdoor work environment with a moderate noise level. Work environment may involve exposure to physical risks, such as blood borne pathogens and operating dangerous equipment or working with chemicals. Evening and/or weekend work may be required. Extended hours and irregular shifts may be required.
As required by P.L. 93-638, absolute preference will be given to qualified Navajo applicants. If there is no qualified Navajo applicant, preference will be given to qualified American Indian applicants.
