PRC Coordinator

POSITION SUMMARY

Under the supervision of the Shingle Springs Health and Wellness Center, Director of Healthcare Operations, the Purchased/Referred Care (PRC) Coordinator will work within established guidelines, determining the need for PRC; and, when appropriate, obligate funds for care within available fund limitations in accordance with governing statutes, regulations, policies, procedures, and established priorities. Shall be responsible for maintaining all PRC files and compliance with the program.

ESSENTIAL FUNCTIONS

1. Establish and maintain a system to effectively coordinate Member Care and PRC programs and carry out the assigned functions.


2. Obtain necessary documentation to prepare authorizations.


3. Process authorizations, denials, and deferred services paperwork promptly.


4. Verify the completeness and accuracy of invoices and supplementary documents returned by providers.


5. Maintain a file for each eligible patient and identify and monitor any alternate resource able to pay for services.


6. Inform patients and providers when alternate resources are available and accessible.


7. Prepare correspondence to patients as needed.


8. Prepare and submit PRC status reports to the Director of Healthcare Operations for the Health Board, as required.


9. Ensure eligibility for each visit and process information accordingly.


10. Assists patients to identify and apply for alternative resources.


11. Tracks all denials, appeals and approvals related to PRC.


12. Obligate funds and prepare purchase requests in accordance with Tribal policy and procedures.


13. Other duties as assigned.

MINIMUM QUALIFICATIONS

1. Ability to type accurately 50 words per minute.


2. Good oral and written communication skills.


3. Managerial experience preferred.


4. Knowledge of patient record keeping requirements desired.


5. High School Diploma or GED required.


6. Must possess valid California driver’s license and be insurable by the Tribe’s auto insurer.


7. Will not use illegal drugs, abuse prescription drugs, or be under the influence of alcohol during work hours. Will agree to blood and/or urine testing for drugs and/or alcohol.


8. Post job offer: CPR/BLS certification, TB test, and annual flu shot (during flu season) are required as a condition of employment, unless a medical/religious accommodation request is provided. Hepatitis B Vaccine will be offered at no cost to employees, but it is not required.

PREFERRED QUALIFICATIONS

1. Knowledge of Federal regulations, guidelines and standards governing Purchased/Referred Care.


2. Experience or Certified Enrollment Counselor with Covered California.


3. Knowledge of HIPPA Law, Privacy Acts and ability to maintain confidentiality of Protected Health Information.

NATIVE PREFERENCE

Preference in hiring is given to either the most qualified applicant or a Native American candidate who meets the minimum qualifications. When two (2) or more Native American candidates have comparable qualifications, the following order of preference shall apply: (1) Members of Shingle Springs Band of Miwok Indians; (2) Spouses or domestic partners (certified through Tribal Court) of members of Shingle Springs Band of Miwok Indians; (3) Parents of children of the Shingle Springs Band of Miwok Indians; (4) All other documented Native Americans; (5) All other applicants in accordance with Title 25, U.S. Code, Section 472 and 473. Applicants claiming Native preference must submit verification of Indian eligibility.