PRC Account Specialist

PRC Accounts Specialist

Department: Purchase Referred Care (PRC)

Reports to: Director of PRC

FLSA Status: Non-Exempt

Type of Position: Full-Time

Revised Date: 07/13/2022

MISSION & VISION STATEMENT:

The Kewa Pueblo Health Corporation (KPHC) is established for the purposes of carrying out the vision and mission of the Santo Domingo Health Center (SDHC). The MISSION of KPHC is: “ENSURING HEALTH & WELLNESS THROUGH EXCELLENCE IN HEALTHCARE WITH RESPECT FOR CULTURE” and the VISION OF KPHC is: “HEALTHY PEOPLE, HEALTHY COMMUNITY, and HEALTHY LIFESTYLE”.

POSITION PURPOSE:

The purpose of this position is to process a wide variety of transactions and compiling reports for Purchased/Referred Care applications and third party billing activity. Work requires identifying transaction types, extracting, compiling and verifying payment data, computing and adjusting account balances, preparing required forms and records, and submitting and maintaining current assignment of benefits.

PERFOMANCE EXPECTATIONS:

In performance of their respective tasks and duties all employees of the Kewa Pueblo Health Center are expected to conform to the following:

• Uphold all principles of confidentiality and patient care to the fullest extent.
• Adhere to all professional and ethical behavior standards of the healthcare industry.
• Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
• Possess cultural awareness and sensitivity.
• Maintain a current insurable driver’s license.
• Comply with all Kewa Pueblo Health Corporation and Santo Domingo Health Center policies and procedures, as well

ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES:

• Performs liaison functions with contract health providers, state and local agencies; and monitors/reports status of PRC activities and funds. Prepares analytical data, staff reports and memoranda which reflect utilization of PRC resources.
• Issues purchase orders in obligating PRC funds and then electronically submit purchase order information to the contracted fiscal intermediary for IHS. Determines those cases that patients may qualify for alternate resources and/or catastrophic health emergency funds.
• Performs high cost case management of expenditures for determining those cases with catastrophic illnesses in order to request and receive reimbursement of Catastrophic Health Emergency Funds.
• Participates in Quality Assurance/Utilization Review by conducting PRC Review Committee meetings.
• Responsible for evaluating pertinent contract health cases and assembling, analyzing and checking statistical data. Advises patients and their families concerning eligibility and other facets of the PRC Program. Plans and develops orientation materials for patients, families, and hospital staff concerning PRC.
• The incumbent considers the personal and medical factors that differ with each patient, such as economic status, educational level, medical problems, treatment methods, and progress of the patient. The specialist identifies the various factors to be considered and advises the physician on specific PRC requirements.
• Offers PRC assistance to eligible Indian people within fund limitations and operates within medical priorities. Conducts on-site patient interviews to establish eligibility for IHS patients for PRC. Provides assistance to individuals applying for services from other sources including Medicare, V.A., CMS and AFDC.
• Initiates Medical Purchase orders to include periods of hospitalization and medical fees for professional services. Responsible for the maintenance of complete Document Control Registers indicating Government appropriated funds for Contract patient care.
• Reviews completed claims submitted by vendors, and EOBRS received from the FI. Returns unclear or incomplete documents to health providers. Compares services provided against contract terms, and enters data to ensure that system operations are accurate. Contacts PRC providers and explains IHS policies and contract care procedures. Establishes and maintains a cooperative working relationship with contract vendor staff.
• Issues correspondence to patients, health care providers and other agencies regarding eligibility, policy and regulations, including letters of denial of claims. Insures confidentiality of patient information. Maintains denial, deferred and appeals tracking for reporting.
• Audits claims processed for patient eligibility for third party programs, proper codes which indicate primary provider code, diagnosis, and clinic code.
• Directs the maintenance of the commitment registers, a daily log of obligations processed. Reviews automated data for comparison with manual data and when errors are detected locates the source and executes appropriate corrective action.
• Performs other related duties as assigned.

MINIMUM MANDATORY QUALIFICATIONS:

Education:

• High School Diploma or GED equivalent

Experience:

• None

PREFERRED QUALIFICATIONS:

• Post-secondary education from Business /Technical School or Associate’s Degree in a related field preferred.
• Two or more years’ experience in duties and responsibilities specified.
• Bilingual skills in English and the Keres Native language
• Prior experience working with Indian Health Services (IHS), a Tribe or Tribal organization
• Knowledge of Contract Medical Care policies and procedures.
• Knowledge of Fiscal Intermediary claims processing procedures both electronically and manually.
• Knowledge of Catastrophic Health Emergency Funds.
• Knowledge of Third party billing systems.
• Knowledge of basic acquisitions and contracting methods.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. This position may be exposed to certain health risks that are inherent when working within a health center facility.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the primary functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk and hear. There may be prolonged periods of sitting, keyboarding, and reading. The employee must occasionally lift and/or move up to 50 pounds.

MENTAL DEMANDS:

There are a number of deadlines associated with this position. The employee must also multi-task and interact with a wider variety of people on various and, at times, complicated issues.

OTHER:

All employees must uphold all principles of confidentiality and patient care to the fullest extent. This position has access to sensitive information and a breach of these principles will be grounds for immediate termination.

Disclaimer: The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position. It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed.