SUMMARY:

Position shall be responsible for initiating, tracking, and processing “payer of last resort” health insurance claims according to United Indian Health Services (UIHS) Purchased Referred Care (PRC) guidelines. 

ESSENTIAL DUTIES AND RESPONSIBILITIES:  

• Maintains PRC files accurately. 
• Have the ability to use or be trained on the use of the various computer software systems used by the organization to perform all job duties.
• Determines if incoming PRC referrals and emergency care notices are within the UIHS approved priorities. Asks for assistance from the PRC Supervisor when needed.
• Prepares and follows up on all referrals including those that need medical and dental review at the Managed Care Committee. 
• Determines if clients meet PRC eligibility requirements, including referral to Alternate Resources for screening and application if eligible. Also requests a copy of approved tribal documentation if necessary for the PRC file.
• Contacts outside providers to request an estimate of charges. Creates purchase orders for eligible approved referrals.
• Communicates and corresponds with outside agencies, provider offices, and clients regarding approved, pending or denied referrals, claim status and other requirements. 
• Communicates and corresponds with UIHS providers to clarify PRC referrals. 
• Tracks PRC cases through the processes of: appointment, outcome, third party insurance eligibility determination, and final claims payment processing. 
• Communicates, tracks and submits purchase orders, or claims to Humboldt Independent Practice Association (IPA) for payment processing. 
• Prepares and submits Catastrophic Health Emergency Fund (CHEF) cases following guidelines from IHS. Notifies supervisor of possible pending CHEF cases so they can be reported to the Member Services Manager and Chief Financial Officer.
• Prepares periodic reports on claims reviewed, pending, and processed to completion.
• Runs monthly reports, exports, and other miscellaneous reports as needed.
• Attends and participates in PRC related meetings at both Board and Administrative levels as needed.
• Must be willing to learn more about the American Indian culture and attend at least one Cultural Presentation/Training per year. 
• Must be willing to work with American Indian/Alaska Native people and demonstrate cultural awareness and humility 
• Must be willing to deliver services in a culturally responsive manner. 
• Adheres to accreditation and compliance standards/guideline
• Other duties may be assigned.

 

 

SUPERVISORY RESPONSIBILITIES:

 

 

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. All individuals must demonstrate a commitment to the provision of culturally sensitive counseling services to American Indians.

 

 

EDUCATION/EXPERIENCE: Educational degrees must be from a US Department of Education accredited school

Level I 

• Must have High school diploma or general education diploma (GED); and
• 0-1 years of clerical office or related experience that indicates the ability to learn the skills necessary to perform the duties of the position. 

Level II 

• Must have High school diploma or general education diploma (GED); and
• 1-2 years of experience working with PRC or other related areas. 
• Knowledge of PRC and able to perform the duties of the position. 
• Ability to work independently and as part of a team. 
• Experience in a health care setting preferred. 
• Able to train level I.

Level III 

• Must have High school diploma or general education diploma (GED); and
• 3 or more years of experience in PRC or related areas and have the ability to perform all the duties of the position. 
• Ability to work independently and as part of a team.
• Experience in health care setting required. 
• Able to train level I or II. 

 

 

COMPUTER OPERATIONS: