Purchased Referred Care Specialist

Job Description:

SUMMARY 

Responsible for processing Purchased/Referred Care (PRC) claims, Tribal member registration, purchase orders, letters of notification, and other duties as assigned.

PRINCIPAL ACTIVITIES & RESPONSIBILITIES

• Provide PRC duties which include, but are not limited to, verifying applicant residency, auditing payment claims, repricing claims, identifying alternate resources, maintaining payment records, identifying claims paid when requested by providers, and providing billing and authorization procedures/requirements to providers.
• Provide telephone customer service for Tribal members to access Purchase Orders and other PRC services.
• Manage applications for the PRC program.  Review applications for completeness, collect eligibility information and enter pertinent data into RPMS to issue authorizations.
• Assist Tribal members with alternate resources/insurance (Marketplace, Medicare, OHP, etc.) applications and interpret alternate resource requirements to Tribal members and providers.
• Process letters for deferred and denied requests for services and other correspondence with Tribal Members.
• Accept and process prior authorizations for treatment from primary care providers.
• Work with our Pharmacy Benefits Manager (PBM) to process pharmacy claims. Work with pharmacies to ensure appropriate management of pharmacy claims.
• Establish and maintain patient and general file system.
• Run monthly RPMS reports and distribute as assigned.
• Develop and maintain relationships with various health providers and vendors, as well as Tribal Enrollment office.
• Attend trainings, classes and seminars to remain current on relevant issues as needed.
• Maintain appearance standards as outlined in CTCLUSI policies.
• Interact with Tribal members and the public in a courteous, professional, friendly, helpful and efficient manner.
• Communicate effectively both verbally and in writing.
• Maintain a good attendance record.
• Other duties as directed by management.

PHYSICAL & MENTAL DEMANDS

• Must be able to walk, talk, hear, use hands to handle, feel or operate objects, tools, or controls, and reach with hands and arms.
• Vision abilities required by this job include close vision and the ability to adjust focus.
• May be required to push, pull, lift, and/or carry up to 40 pounds.

WORKING CONDITIONS & ENVIRONMENT

• Moderate noise level with frequent interruptions and distractions.

JOB LOCATION

Tribal Administrative Office
1245 Fulton Avenue
Coos Bay, Oregon 97420

Experience and Skills:

MINIMUM JOB REQUIREMENTS

• Must be at least 18 years of age.
• Associates Degree in Medical Accounting / Medical Accounts Payable with two or more years of experience post education or any combination of education, experience and training which must include experience in Purchased and Referred Care (Contract Health), RPMS, Oregon Health Plan, private insurance, Medicare, and/or the Marketplace.
• Preference will be given to applicants who have recent experience working with RPMS, Purchased and Referred Care, claims, EOBs, third party reimbursements or provider offices.
• Working understanding of CPT codes, ICD-9/10 codes and medical terminology.
• Excellent customer service skills required.
• Demonstrated computer proficiency, including MS Word, Excel and Outlook.
• Must be able to pass a computer test.
• Must have experience and ability to multi-task.
• Must be able to work with local, state and federal health agencies required.
• Must possess reasonable ability to communicate in English.
• This position is subject to pre-employment drug testing.
• This is a covered position which requires background check that includes fingerprinting.
• Must have employment eligibility in the U.S.
• Indian preference will be observed in the hiring process.