Purchased/Referred Care Representative - Suttons Bay, United States - Grand Traverse Band of Ottawa and Chippewa Indians

Description

Job Description

SUMMARY Assist in the administration and coordination of the Purchased/Referred Care Services Self-Governance Compact Health files, computerized FCP Gateway management system, Resource Patient Management System (RPMS), software systems relevant to position as needed, and act as liaison between clients, providers, and Third-Party Administrator. This position will be assigned 3 counties of our GTB 6 County Service Area as a representative you will be responsible for all claims status, eligibility and customer service to create a well-rounded, efficient department. In addition, this position will include Tribal Premium Sponsorship Program responsibilities. Excellent customer service a must.

MINIMUM QUALIFICATIONS

• Must have a High School diploma or GED.
• Minimum of one-year post high school in Business Administration or health related fields.
• Must have a valid unrestricted Driver's License and be insurable by the GTB insurance carrier.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Maintain the FCP Gateway management system, including client and vendor files
• Maintain the computerized Voucher Management System including client and vendor files, budget management files, and computerized commitment register.
• Determine eligibility for enrollment in FCP Gateway program by collecting appropriate documentation from applicants.
• Access the FCP Gateway computer system to add, change and delete contracts for clients as necessary.
• Maintain data files in IHS-provided RPMS computer system to assure that credit for client contact is received by the Tribe at the national level.
• Answer written and telephone inquiries from clients and health care providers on behalf of the GTB Health Department.
• Adjust and approve vouchers for payment and submit payment approval requests to the accounting department.
• Work with Patient Registration to streamline patient eligibility/registration.
• Serve as a tribal member/client advocate with area hospitals/providers.
• Collaborate with Benefits Coordinator to ensure clients apply for all eligible medical benefits (i.e., Medicaid, Medicare, etc.) Assist in determining medical eligibility and work with client to apply for Medicaid.
• Tribal Premium Sponsorship Program responsibilities:
  • Assist in determining eligibility in the Tribal Premium Sponsorship Program and work with client(s) to apply for Sponsorship, working collaboratively with the Benefits Coordinator and other Department Staff. Must train and pass to become Certified Assistor through the Marketplace Learning Management System (MLMS) with Center for Medicare and Medicaid Services (CMS).
• Maintain manual files of check copies, vouchers, contracts, and other documents pertinent to the activities of the health program.
• Assure the proper classification of voucher and other commitments or expenditures in order to facilitate the preparation of monthly reports for submission to IHS Compact. Assist in preparation of monthly report package.
• Obtain periodic training and upgrading as appropriate to maintain professional skills and stay current in modern health issues.
• Comply with Health Insurance Portability and Accountability Act (HIPAA) regulations at all times.
• Attend Tribal Council and Health Committee meetings when necessary, and provide assistance and advice as requested.
• Customer service primary focus and tasks include, but not limited to answering telephones, greeting clients needing assistance, and filing.
• Eligibility focus and tasks include, but not limited to addressing PRC client eligibility requirements and questions with clients and vendors. This includes internal and external Providers as well.
• Claims focus and tasks include researching claims information for clients, vendors, and Providers utilizing the FCP Gateway system, RPMS, and paper files, and include eligibility as well.
• Maintain patient confidentiality as per Health Insurance Portability and Accountability Act (HIPAA) of 1996 and complete HIPAA compliance training.
• Other duties as assigned that relate to the health needs of the membership and the IHS Compact/Annual Funding Agreement.
• Other duties as assigned.

OTHER SKILLS AND ABILITIES

• Must have good oral and written communication skills
• Must be self-starter and have excellent organizational skills
• Work requires proficiency in computer literacy, preferably in Microsoft Windows, Word, Excel, Outlook, and other Microsoft office products and database applications.
• Must have good interpersonal skills with demonstrated patience, tact, and respect.
• Uses good judgment in interpreting guidelines, in adapting department procedures, or in recommending approaches or solutions for specific problems
• Must have outstanding verbal and written communication skills.
• Must have good time management and organizational skills
• Excellent interpersonal skills with demonstrated patience, tact, and respect.
• Ability to work independently, with people in a group setting, and be a team player.
• Exceptional detail and follow-up skills are critical.
• Must have good customer service skills.
• Must be reliable and maintain confidentiality.

EDUCATION and/or EXPERIENCE

• Must have a High School diploma or GED.
• Minimum of one-year post high school in Business Administration or health related fields.
• Equivalent experience may be considered in lieu of education.*

DRIVING REQUIREMENTS

Must have a valid unrestricted Driver's License and be insurable by the GTB insurance carrier.

SUPERVISORY RESPONSIBILITIES

EQUIPMENT TO BE USED

General office equipment including but not limited to computer, copier, calculator, fax machine, and telephone.

TYPICAL PHYSICAL DEMANDS

Travel throughout the six-county service area required. Requires sitting, lifting, reaching and walking. Some lifting of small office equipment up to 25 lbs. Also requires manual dexterity to operate office equipment.

TYPICAL MENTAL DEMANDS

The employee uses judgment in identifying and selecting the most appropriate procedures to use, or in determining which of several established alternatives to use. Deadlines are involved so there is time pressure on occasion.

WORKING CONDITIONS

A good deal of work is performed in an office setting. Working at GTB Satellite locations is required and the expectation is there may be travel within the six-county service area.

COMMENTS

Native American preference will apply. Must be willing and able to pass a background investigation and a drug and alcohol urinalysis as a condition of employment. Adherence to strict company policy in regard to confidentiality is a must.

The above statements are intended to describe the general nature and level of work performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Management retains the right to add or to change the duties of the position at any time through approved motion by Tribal Council. * Any qualifications to be considered as equivalents in lieu of stated minimums require prior approval of the Director of Human Resources.