Job Description

Job Description

Job Description

PLEASE NOTE - This position may require temporarily relocation to other TONHC Fa cilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

Position Summary:

The incumbent is responsible for administering the Purchased/Referred Care (PRC) program. Responsibilities include allocating PRC funds and alternate healthcare resources to provide complete comprehensive health services for Tohono O'odham Nation Health Care's user population.

Scope of Work:

This position is located within Tohono O'odham Nation Health Care's Purchased Referred Care (PRC) Branch or Administrative Office. It may be situated organizationally and duty stationed at any TONHC facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

Essential Duties and Responsibilities: (Depending on the area of assignment, an incumbent may not be required to perform some of the duties listed below):

• Maintains collaborative measures with the clinical teams to assure initial and process follow-up patient referrals according to the current PRC mapping process for the health care facility.
• Responsible for determining patient eligibility, scope, and priority for the PRC program.
• Responsible for entering necessary referrals into the RCIS system.
• Assists patients in the scheduling of referred appointments.
• Provide education to patients on special instructions for referred visits.
• Follows up on referred visits scheduled to ensure the referring facility receives the visit records.
• Follows up with patients after referred visits to coordinate follow-up primary care visits as necessary.
• Respond to PRC inquiries and requests for PRC assistance from the clinic staff and patients.
• Respond to inquiries and requests within the TONHC Healthcare facilities, including medical, social service, dental, and private sector health resources regarding PRC referral status.
• Responsible for implementing decisions made for the provision or denial of services.
• Responsible for effective and maximum utilization of PRC funds and maintaining a follow-up system that will assure adequate funds are set aside for all authorized referrals, emergency notifications, and follow-up care referrals per policy and clinic mapping process.
• Assures obligation of all funds by the end of the funding period.
• Assures the cancellation of all unused obligations on a timely basis.
• Assures all outstanding authorizations over 30 days old are valid.
• Assures authorizations are only processed when funds are available.
• Assures transactions affecting funds are promptly processed; this includes obligations, disbursements, cancellations, reconciliation, and recording allocations.
• Assures effective communication with fiscal intermediaries and Finance, responding to all pending claims.
• Maintains the Nation's commitment to registering for PRC funds for medical and dental services.
• Responsible for maintaining a register for all requests for additional funding.
• Compiles statistical and fiscal data reports necessary to determine funds required to meet the PRC program's needs.
• Prepare all PRC financial status reports, budget needs, forecasts, and other required PRC reports for the Hospital.
• Reconciles with Financial Management Reports and Fiscal Intermediary, keeping supervisor and Hospital and clinic staff advised on current fund status.
• Assist with reporting Catastrophic Health Emergency Fund (CHEF) cases. Works closely with PRC staff and medical officers to report, manage and monitor the high-cost cases funded through the CHEF program established by P.L. 100-173 Section 202.
• Responsible for keeping up-to-date pending and completed PRC patient files with a documented status of all written and verbal transactions.
• Performs periodic spot reviews and audits of completed authorization forms and other documents to ensure the consistent, correct use of allotment, object, sub-object, and sub-activity coding required.
• Works with Hospital and Clinic professional and para-professional staff, local providers, tribal health committees; serves as a representative at meetings to create and understand the PRC programs and promote consumer and provider satisfaction.
• Incumbent must know computer applications relating to the PRC Program, including the responsibility for key entering and verifying all PRC service authorization, payments, cancellations, and supplements.
• Responsible for adding, deleting, changing, and verifying information in both the patient file and vendor.
• Contribute to a team effort.
• Other duties as assigned.

Knowledge, Skills, and Abilities:

• Knowledge of the Tohono O'odham culture, customs, and traditions.
• Knowledge of applicable federal, state, tribal laws, regulations, and requirements.
• Knowledge of legal regulations and requirements on confidentiality, specifically the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Knowledge of the various TONHC program functions related to the Purchased/Referred Care program.
• Knowledge of funds control techniques to account for the funds allotted to the Purchased/Referred Care Program; a comprehensive ability to prepare financial statements and reports.
• Knowledge of medical codes derived from the Indian Health Service Standard Code Book and the Contract Medical Care System Handbook.
• Skill in communicating with people from varied backgrounds and cultures, including communicating effectively with a wide variety of people, especially interaction with irate patients.
• Ability to learn Purchased/Referred Care guidelines and regulations necessary to assure that the prescribed procedures are appropriately applied.
• Ability to obtain in-depth knowledge of all computer operations and sequence execution of Purchased/Referred Care programs and the online peripheral devices' relationship to the computer system.
• Ability to define PRC services, determine eligibility, how PRC supports direct care, federally recognized Indian Tribe, reservation, residency, descendancy, tribal affiliation, CHSDA, close social and economic ties, elderly, disabled, alternate resources, and medical priority levels.
• Ability and skill to coordinate the PRC office with others (i.e., vendors, physicians, support services, state agencies, etc.)
• Ability to prepare good oral and written communication to interact with referral program personnel, contract care facilities, and providers.
• Ability to work independently, use sound judgment, and meet deadlines.

Minimum Qualifications:

• High School Diploma or General Education Diploma and one year of work experience in a medical business office function, or an equivalent combination of training, education, and work experience demonstrate the ability to perform this position's duties.

Licenses, Certifications, Special Requirements:

• Must possess and provide a copy of an official record that verified the training received with the employment application.
• Must possess a certification of completing an approved medical assistant training program accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP), the Accrediting Bureau of Health Education Schools (ABHES), or any accrediting agency recognized by the United States Department of Education. OR ;
• A current and active Certified Medical Assistant (CMA) or Registered Medical Assistant (RMA) from The American Association of Medical Assistants (AAMA) or the American Medical Technologists (AMT). OR ;
• The completion of a medical services training program of the Armed Forces of the United States.
• Must provide a copy of an official record that verifies the training received.
• Must obtain an Arizona Notary Public Commission certificate within six months of hire.
• Upon recommendation for hire, a criminal background and a National FBI fingerprint check are required to determine suitability for employment, including a 39-month driving record.
• May require possessing and maintaining a valid driver's license (no DUIs or major traffic citations within the last three years).
• If required, must meet the Tohono O'odham Nation tribal employer's insurance requirements to receive a driver's permit to operate program vehicles.
• Based on the department's needs, the incumbent(s) may be required to demonstrate fluency in both the Tohono O'odham language and English as a condition of employment.

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