Purchased Referred Care Case Manager

POSITION SUMMARY

Maintain a centralized medical referral and case management system working closely with internal and external medical staff/providers. Serve as an advocate for patients being referred for outside services. Establish accounts payable process and procedures for purchase order system. Collect, review, and analyze billing for referral services. Process payments to medical institutions and coordinate case management of referral services. Identify patient eligibility for payment with established PRC protocol and policy. Perform outreach efforts to facilitate patient compliance/access; tracking patient’s ER/specialty visits and hospital follow-up care; identifying/ utilizing all appropriate available community/alternate resources; communicate, plan and coordinate with clinical case management or disease management staff; as well as supporting care management. Provide support and technical assistance for payments, co-pays and denials for the PRC Program.

ESSENTIAL FUNCTIONS

Coordinate referrals and appointments with medical specialists, including determining patient’s health care payment and eligibility resources; obtain insurance pre-authorizations; medical notes, demographics, and billing information; track patient appointments to completion; arrange for transportation; ensure the patient has proper follow-up until medical care is complete.

Maintain compliance with Indian Health Services PRC Health Services program regulations and internal program policies and procedures to include the maximum utilization of alternate resources.

Work closely with revenue cycle, business office, health center providers/Medical Review Team to ensure that all external medical/dental professional referrals are medically appropriate and with medical/dental priority.

Make appointments and issue purchase orders (PO) for patients being referred outside of the Health Center; Business Office, and the Insurance Specialist to determine CHS eligibility and payment of POs.

Monitor and track patient referrals until billing is available, flag and follow up on overdue reports. Monitor the timeliness and quality of the referral process.

Coordinate arrangements between payor and payees.

Systematically identify patients with unplanned hospital admission and emergency department visits.

Coordinate with families/caregivers for follow-up of patient billing and payment. Request summaries and documentation from hospital and other facilities.

Properly enter/record patient information in electronic medical records. Maintain accurate, detailed reports and records.

Identify errors, omissions, duplications, discrepancies or other inconsistencies in medical documentation and billing. Contact the appropriate individuals to resolve problems.

Prepare accurate and timely reports for management to aid in the analysis PRC claims/bills paid, in process and denied, etc.

Participate in QI health department meetings, program planning, evaluations & improvement strategies to minimize problems and optimize operation efficiency.

Display a positive and professional manner and promptly respond to all requests, complaints, and problems.

Follow data privacy guidelines and safeguards for payment of claims/bills and medical records; maintain confidentiality and professional ethics at all times.

Work cooperatively as part of a team and promote teamwork with co-workers.

MINIMUM QUALIFICATIONS

Two (2) years purchased referred care or directly applicable experience such as processing medical claims and/or payments for healthcare billing.

High School Diploma or GED.

KNOWLEDGE, SKILLS AND ABILITIES

To perform this job successfully, an individual must be able to perform each responsibility satisfactorily. These requirements are representative, but not all-inclusive, of the knowledge, skill, and ability required for this position.

1. Knowledge of PRC codes and regulations.

2. Case management and patient care coordination and chronic disease management and tracking.

3. Knowledge of Health Care Delivery Systems.

4. Familiar with Contract Medical Care policies and procedures

5. Familiar with Fiscal Intermediary claims processing procedures both electronic and manual.

6. Familiar with Catastrophic Health Emergency Funds.

7. Knowledge of Revenue Cycle Management (RCM).

8. Knowledge of basic accounting methods.

9. Knowledge of medical terminology, medical record keeping and the standard format for information on charts and other medical documentation.

10. Safety principles, practices and equipment related to the work.

11. Techniques for dealing with a variety of individuals from various socio-economic, ethnic and cultural backgrounds, in person and over the telephone.

12. Assessing client medical status and situations and taking or recommending appropriate action.

13. Coordinating health care of patients between multiple health facilities.

14. Organization, follow-up, tracking and trending patient health data.

15. Interpreting, applying and explaining applicable laws, codes and regulations.

16. Preparing accurate, clear and concise medical documentation and records.

17. Compiling and summarizing information and preparing periodic or special reports related to patient billing and case management.

18. Using tact, discretion and prudence in dealing with patients.

19. Using initiative and independent judgment within established procedural guidelines.

20. Establishing and maintaining effective working relationships with a variety of individuals from various socio-economic, ethnic and cultural backgrounds. Knowledge of Alternate Resources Program operations, priorities and goals.

21. Knowledge of all third-party claims submission process and ability to keep current on changes in policies, regulations of eligibility.

22. Knowledge of coding procedures/ ICD-CM and CPT coding, hospital discharge definitions regarding diagnostic and procedural sequencing in order to interpret and resolve problems.

23. Knowledge of how to establish and maintain relationships with the third-party payer community necessary for resolution of outstanding claims.

24. Knowledge of the RPMS and EHR.

25. Keeps abreast of current changes in government regulations, collection laws, FTC ruling, third party procedures and internal procedures.

26. Ability to exercise considerable tact in maintaining effective work relationships with various employees, clients and patients. Position requires extreme accuracy and timeliness in all phases of work.

27. Knowledge of Privacy Act of 1974, HIPAA, and the use of confidential information and health records as an integral part of the privacy of individuals, which must be fully protected.

28. Ability to deal with conflicting situations in a patient and sensitive manner.

29. Ability to meet deadlines and prioritize workload. Must have strong organizational skills.

30. Strong verbal and written communication skills

31. Ability to work effectively with minimal supervision.

32. Knowledge of Microsoft Office Suite (Word, Excel, etc.), internet and email software.