The Patient Care Coordinator, under the direction of the Contract Health Utilization Manager, is responsible for assisting eligible Tribal members residing within 7 county service area in accessing federal health funding through Purchased Referred Care Program.  The position is responsible for processing claims for payment for health care referrals from Sault Tribal Health Clinic Providers, Urgent/emergent care, Inpatient Hospital services. The position is responsible for coordinating care for member to outside Providers for durable medical equipment, non-formulary prescriptions and other medical necessities.

 essential functions: (includes, but is not limited to, the following)

Assist members in applying for Purchased Referred Care and/or alternate resources if eligible both for Federal and Tribal programs and clearly explains program and provides members with informational resources on the eligibility policies for Purchased Referred Care. Records requests for prior authorization from members for referral visits to outside providers and/or urgent emergency room/urgent care hospital visits. Works with referral coordinators/providers from each Tribal Health Center locations for referral processes to determine priority status and approval of services. Records referrals in Purchased Referred Care program under each member’s name. Enters data into Purchased Referred Care Voucher Program for covered services and forwards authorization vouchers to providers. Enters data into Purchased Referred Care Voucher Program for services deemed not covered and forwards denial letter to members with information on Appeal Process and timeliness for filing an appeal to Health Board.   Coordinates with hospital admissions department on Purchased Referred Care application process for members who are admitted and not have applied for Purchased Referred Care.  Works with hospital discharge planner to coordinate the care of member being released from the hospital needing specialty care items/Durable medical equipment needed in the home and tribal program services such as Eldercare Services and Community Health Services and local agency services. Processes covered claims received in from providers in Purchased Referred Care Voucher Program for payment and communicates with outside vendors on processing aged or opened accounts over 90 days past due. Ensures new providers’ complete W-9 forms and then forwards form to the Accounting Department for inputting information into new vendor database. Assists members with non-formulary medications prescribed by Tribal provider for coverage at outside contracted pharmacies. Faxes eligible members’ names daily to contracted pharmacies. Determines if RX is a payable item under Purchased Referred Care to decide if it cost effective to obtain at a local contracted pharmacy or to “Special Order” thru our Tribal Clinic Pharmacy at “340b” pricing. Identifies and refers high-cost member medical cases to Certifier. Expedites payment process by contacting Providers and identifying medical claims for CHEF (Catastrophic Health Emergency Fund) fund reimbursement. 

additional responsibilities: (includes, but is not limited to, the following) 

Directs, coordinates, and communicates complex and vast amount of information involved to our members regarding services provided through Purchased Referred Care. Carries out the program with guidelines set forth under the Indian Health Care Improvement Act, Public Law 94-437 and Federal Medical Care Recovery Act and Indian Health Service Policy Regulations on Eligibility and Alternate Resources, Purchased Referred Care Review Committee, Board of Directors, Health Director and Contract Utilization Manager. All other job-related duties as assigned.

 Contacts:

Immediate peers, peers in other departments, immediate supervisor/manager, managers in other departments, Executives, Board of Directors, customers, outside vendors/service providers, Tribal Providers, Physicians Assistants and Nurse Practitioners.

physical requirements: 

Position is sedentary, primarily sitting/lifting of maximum of 10 pounds. Physical factors include constant sitting, use of hearing and typing; frequent use of near and midrange vision; and occasional standing, walking, carrying/lifting, climbing, reaching, manual handling, driving and bending. Working conditions include frequent exposure to air quality and exposure to traditional medicine ceremonial burnings and occasional exposure to noise. Potential hazards including constant computer use; frequent infectious exposure, patient contact and/or client contact and equipment.

REQUIREMENTS:

Education: High school diploma or equivalent required.

Experience: Minimum of two years of office experience working in a medical/clinical business office required. 

Certification/License: Must maintain a good moral character standing. Will be required to complete and pass pre-employment drug testing.

Knowledge, Skills and Abilities: Must have excellent public relation/customer service skills and be able to exhibit a friendly and positive attitude. Must have knowledge of medical terminology, and of ICD9-CM and CPT Codes used in billing practices.  Must have excellent communication skills and be able to communicate clearly in person, in writing, and by telephone and email.  Must be able to work in a high volume and fast paced environment. Must be able to work with minimal to no supervision. Must be able to work under pressure and handle difficult situations. Must maintain confidentiality. Native American preferred