Job Title: Administrative Medical Assistant - PRC

Department: Tohono O'odham Nation Health Care (TONHC)

Division: Purchased Referred Care

Status: Non-Exempt/Full-time

Salary: $19.15 - $23.92/hr. (DOE)

Position Summary:

Incumbent is responsible for the administration of the Purchased/Referred Care (PRC) program. Responsibilities include the allocation of PRC funds and alternate health care resources in order to provide total 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, and may be organizationally located and duty stationed at any of the 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 assist in coordinating 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 implementation of 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 register for PRC funds for medical and dental services.
• Responsible for maintaining a register for all requests for additional funding.
• Compiles reports of statistical and fiscal data 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 the reporting of 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 as 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 to the Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Knowledge of the various TONHC program functions as they relate to the Purchased/Referred Care program.
• Knowledge of funds control techniques to account for the funds allotted for 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 different 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.