Job Title: Purchased Referred Care (PRC) Clerk
Department: Purchased Referred Care (PRC)
Reports To: Purchased Referred Care Coordinator
Salary Level: Grade 7 Step 1-12 ($18.62 - $25.09)
FLSA Status: Non-exempt
Approved By: Chief Executive Officer
Approved Date:
GOALS FOR POSITION: PRC clerks will receive training in the Referred Care Information System (RCIS) and Contract Health Services (purchase order system).
SUMMARY: Position shall be responsible for initiating, tracking, and processing “payer of last resort” health insurance claims according to K’ima:w Medical Center (KMC) and Indian Health Service - Purchased Referred Care (PRC) guidelines.
FUNCTIONS & RESPONSIBILITIES:
1. Maintains PRC files accurately.
2. Have the ability to use or be trained on the use of the various computer software systems used by the organization to perform all job duties.
3. Determines if incoming PRC referrals and emergency care notices are within the KMC-approved priorities. Asks for assistance from the PRC Supervisor when needed.
4. Prepares and follows up on all referrals, including those that need medical and dental review at the Managed Care Committee.
5. Determines if clients meet PRC eligibility requirements, including referral to Alternate Resources for screening and application if eligible. Requests a copy of approved tribal documentation if necessary for the PRC file. Requests Residency Verification when necessary.
6. Contact outside providers to request an estimate of charges. Creates purchase orders for eligible approved referrals.
7. Communicates and corresponds with outside agencies, provider offices, and clients regarding approved, pending or denied referrals, claim status and other requirements.
8. Communicates and corresponds with K’ima:w clinical providers to clarify PRC referrals.
9. Tracks PRC cases through the processes of: appointment, outcome, third-party insurance eligibility determination, and final claims payment processing.
10. Communicates, tracks, and submits purchase orders or claims for payment processing.
11. Prepares and submits Catastrophic Health Emergency Fund (CHEF) cases following guidelines from IHS. Notifies supervisor of possible pending CHEF cases so they can be reported to the appropriate approving officials.
12. Prepares periodic reports on claims reviewed, pending, and processed to completion.
13. Runs monthly reports, exports, and other miscellaneous reports as needed.
14. Attends and participates in PRC-related meetings as needed.
EDUCATION and/or EXPERIENCE:
High School Diploma or equivalent G.E.D, and six months to one-year related experience and/or training or equivalent combination of education and experience.
CERTIFICATES, LICENSES, REGISTRATIONS:
•Current CPR Certificate.
•Valid California Driver's License.