Purchased/ Referred Care Specialist

Job Code: 29-2072 

Salary: $16.10-$31.68

Status: Full-Time, Permanent, Non-Exempt 

Department: Business Office

Location: Health Services 

Reports To: PRC Supervisor

Telecommute: No 

Fleet: No

Mandated Reporter: Yes 

Background: PL101-630

SUMMARY: Under the direction of the Purchased/Referred Care Supervisor, the Purchased/Referred Care Specialist in the Purchased/Referred Care department will compile, process and maintain accounts payable of Health Services in a manner consistent with medical, administrative, ethical, legal and regulatory requirements in all areas of the Business Office. The Purchased/Referred Care Specialist assumes responsibility for processing payment of purchased/referred care expenditures to outside providers after the patient’s alternate resources have been utilized.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

• Analyzes and processes health claims, medical records, and explanations of benefit (EOB) that outside providers submit to the Aither billing system for payment of any unpaid balance owing for authorized and approved patient referrals.
• Processes coordination of insurance benefits as required for processing payments.
• Prepares the Explanation of Benefits (EOB) statement after the patient’s alternate resources is billed for each episode of care, as P/RC is payor of last resort.
• Maintains knowledge of the P/RC program, P/RC policies and procedures, payment processes, including eligibility for services and alternate resource policies.
• Medicare-like Rates (MLR) apply to health claims where applicable.
• Processes health claims/bills within 15 business days.
• Submits required documentation to supervisor and administration for review and payment authorization and make corrections as needed.
• Submits the approved payment voucher electronically to Finance for check request via Adobe Sign.
• Reviews EOBs and confirms that all purchase orders are linked to an authorized episode of care.
• Ensures medical records for each episode of care have been scanned to the patient chart.
• Creates purchase orders and payment vouchers for the Purchased/Referred Care program.
• Ensures the vendor’s name, vendor amount, and the correct payment funding source, referral and service class code are properly applied to each transaction.
• Initializes batch files and semi-weekly check runs and posts each payment to the patient chart.
• Prints, sorts and mails checks, along with the Health Services EOBs, to outside provider offices.
• Reviews/enters patient statements in purchased referred care systems.
• Responsible for filing all financial documentation in sequential order. · Verifies and updates patient’s alternate resources in the Aither billing system as needed.
• Verifies and updates patient’s alternate resources in the Business Office emergency department log.
• Processes request for refund of payments from Outside Providers when new insurance is identified.
• Assists Business Office Manager and Purchased/Referred Care Supervisor with Medicare reimbursements, patient consents, and distribution of payments to eligible members.
• Train new/inexperienced staff as needed.
• Processes ACH/EFT requests for purchased/referred care payments.
• Processes SRMT Finance Vendor forms in Adobe Sign as needed.
• Scans documentation in OnBase electronic filing software.
• Maintains up-to-date knowledge of third-party insurance billing policies and procedures (including Medicare, Medicaid, and private insurance).
• Able to always deal with patient(s) sensitively and professionally.
• Assists in the development and modification of Business Office policies and procedures.
• Attends meetings/trainings as requested by the Supervisor and Business Office Manager.
• Assures HIPAA compliance with regard to accounts payable practices.
• Other related duties as assigned (including Patient Registration, Health Information Management, Purchased/Referred Care, Third Party Billing, Accounts Receivable, and Referrals).

MANDATED REPORTER: Must become a mandated reporter and maintain that status throughout employment. This includes completing any necessary training and adhering to all reporting obligations as defined by applicable laws and tribal policies.

SUPERVISORY RESPONSIBILITIES: There are no supervisor requirements for this position.

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Due to the sensitive nature of information and personnel files maintained within Human Resources, must always maintain strict confidentiality.

EDUCATION and/or EXPERIENCE: High School diploma or equivalent and one-year medical office billing with claim processing.

Preferred: High School diploma or equivalent and two years’ medical office billing with claim processing.

OTHER SKILLS and ABILITIES: Strong oral and written communication skills required. Must have excellent computer skills including word and excel.

REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

The Saint Regis Mohawk Tribe strives to be an equal opportunity employer dedicated to the policy of nondiscrimination based on race, sex, marital status, sexual orientation, religion, national origin, age, physical disability, veteran status or any other non-job-related factor.

The successful candidate must pass a test for illegal substances prior to employment being confirmed.

The successful candidate must pass a criminal background check prior to employment.

The successful candidate must submit a PPD prior to employment