Job Announcement: HR2023:08

Position Title: Purchased and Referred Care Specialist/Resource Coordinator

Advertising: Publicly

Department: Health

Division: Health & Elder Services

Immediate Supervisor: Director-Purchased/Referred Care

Department Director: Director-Health

Employment Status: Non-Exempt

Position Type: Regular Full–Time

Mandatory Reporter: Yes

Background Check Required: Yes (data-sensitive)**

Opening Date: Wednesday, January 11, 2023

Closing Date: Wednesday, January 25, 2023 by 5:00 p.m.

Preference shall be given in accordance with the Title 33 (Tribal Employment Rights) of the Tribal Code/DFWP.

Overall Objectives of Position The Purchased and Referred Care Specialist/Resource Coordinator is responsible for reviewing and assessing claims and bills for payment of patient’s medical services provided by off- site specialties, including unscheduled emergency care reported within the designated period. The Purchased and Referred Care Specialist/Resource Coordinator is also responsible for maintaining patient files that include referrals and seventy-two (72) hour notifications, and assist the Purchased/Referred Care Director by providing necessary administrative support duties. The Purchased and Referred Care Specialist/Resource Coordinator utilizes the Healthcare Marketplace to assist patients with accessing health insurance for all health care services, both in and out of the Tribal Health Department. This job description is not an all-inclusive list of the duties and responsibilities of this position. The Purchased and Referred Care Specialist/Resource Coordinator will perform all duties and responsibilities necessary to meet the goals and objectives of applicable programs. The Purchased and Referred Care Specialist/Resource Coordinator is expected to live the Purpose and Values of the Poarch Band of Creek Indians and go beyond the call of duty

Primary Responsibilities of the Purchased and Referred Care Specialist/Resource Coordinator

• Acts as a back-up as needed in absence of Director-Purchased/Referred Care.
• Manages referral system to guarantee timely and accurate payments for authorized medical services. Ensure that appropriate documentation supports each claim for payment, taking care to seek Medicare like rates when feasible.
• Computes accurate Purchased/Referred Care obligations per purchase orders upon receipt of authorization for payment.
• Records incoming seventy-two (72) hour notifications. Adhering to established privacy and protected health information standards, appropriately request all documents required to review the emergency treatment administered by an outside provider.
• Renders payment for seventy-two (72) hour notifications that are approved by appropriate medical staff on site; issue denials, or “no pre-authorization” letters for those notifications that do not meet criterion.
• Establishes and maintains a centralized filing system for the Purchased/Referred Care Office. The ability to maintain and search records is essential.
• Works closely with Patient Registration to Verify patient insurance using OneSource system and relays this information to the appropriate departments
• Provides clerical and office support for the Business Office
• Acts as a liaison between the Poarch Creek Indians Health Department and various social services and health organizations.
• Researches, documents, implements and utilizes the healthcare marketplace to assist patients in accessing and maintaining health insurance.
• Assists patients with completing applications for various health care options. These include Alabama Medicaid, All-Kids, Medicare Parts B and D, and Marketplace coverage
• Upholds patient confidentiality and adhere to the HIPAA and the Privacy Act laws.
• Performs other duties as assigned by appropriate person.

Day-to-day Responsibilities

• Reviews incoming mail, making sure the patient has the required information on file in order to consider payment for medical services.
• Obligates purchase orders for payment.
• Calls outside providers requesting the required documentation for payment.
• Works closely with Patient Registration and Insurance Verification Specialist for updated insurance information
• Maintains a comprehensive and current data resource file of alternate healthcare resources
• Coordinates alternate resource/PAR activities with clinic staff to ensure full utilization of alternate resources, including, ACA insurance coverage, Tribal self-insured plan, Medicare parts A,B,D, and Medicare like rates for referrals.
• Works as a team member to meet or exceed departmental goals and customer satisfaction
• Complies with all Federal and State laws/regulations

Education/License/Certification and Experience Requirements

• Associate’s Degree in Business Administration or related field with five (5) years of employment experience in a confidential health care setting and/or a combination of related education and employment experience in a confidential health care setting equivalent to seven (7) years required.
• CMS Marketplace CAC certification preferred. Must obtain within twelve (12) months of hire date.
• Verifiable knowledge of Medical Terminology and ICD9/ICD10 and CPT coding.
• Experience in a Windows environment and software programs such as Word and other similar software programs required.
• Knowledge of Medicare, Medicaid and third party insurance and health care resources required.
• Knowledge of medical terminology and abbreviations required.

Skills Required

• Must maintain confidentiality of records relating to patient’s treatment and adhere to all laws relating to HIPAA.
• Knowledge, skills, and abilities in operating healthcare computerized data entry.
• Adept at multi-tasking, have unquestionable integrity, with an uncompromising commitment to quality.
• Must be detail oriented and highly organized.
• Exceptional interpersonal and communication (verbal and written) skills.
• Must have excellent phone etiquette.
• Must be able to effectively work and communicate with other staff members, patients and their families, health care professionals and the public.
• Must be people oriented and relate well to people from diverse backgrounds.

Additional Requirements

• Must meet CMS Covid Vaccination Requirement or be approved for a qualified medical or religious exemption prior to employment.
• Ability to work odd and irregular hours, as needed.
• Must successfully pass the required criminal and character background check.
• Must possess a valid driver’s license and insurable driving record according to Tribal insurance guidelines.
• Ability to travel and participate in required training, leadership development, and other events.
• Ability to adequately and successfully perform all duties and responsibilities of this position

Every applicant must complete an application provided by Human Resources. A resume will not be accepted in the place of an application.

**Please note ALL individuals selected for employment are required to complete a background investigation. Individuals being placed in positions designed as child-sensitive or data-sensitive must successfully complete a background check prior to employment.

INDIAN PREFERENCE, SPOUSAL PREFERENCE, OR FIRST GENERATION:

In the event more than one applicant meets the requirements, as stated in a job description, preference shall be given in the following order: (1) Tribal Member (2) First Generation Descendant of a Tribal Member (3) Spouse of Tribal Member (4) Indian (5) Non-Indian

In the event that a position of employment is funded in whole or in part my any federal grant and/or contract or other public funding, preference shall be given in the following order: (1) Indian (2) Non-Indian

In order to receive preference, the appropriate documentation must be submitted.

COMPLAINTS ABOUT RECRUITMENT PROCESS:

Complaints about the recruitment or selection process for employment should be directed in writing to the Human Resources Director of PCI Tribal Government.

An applicant who disagrees with any issue related to the application or hiring process may submit a letter to Human Resources within ten (10) calendar days from the date the applicant knew or should have known that an adverse hiring decision had been made.

Human Resources will provide a written response within fourteen (14) calendar days informing the applicant of any administrative remedy to be provided. The decision of the Human Resources Director shall be final and not subject to further administrative appeal. Any applicant who has exhausted all administrative remedies may be eligible to file a complaint with the TERO Office.

Jason B. Rackard

Human Resources Director

5811 Jack Springs Rd.

Atmore, AL 36502

jrackard@pci-nsn.gov

251-368-9136

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