Purchased/Referred Care (PRC) & Referrals Specialist

800x600 Normal 0 false false false EN-US X-NONE X-NONE MicrosoftInternetExplorer4 Normal 0 false false false EN-US X-NONE X-NONE Normal 0 false false false false EN-US X-NONE X-NONE Normal 0 false false false false EN-US X-NONE X-NONE Job Announcement Position Title : Purchased Referred Care (PRC) & Referrals Specialist Department: Health Information Management Supervised By : Health Information Management Director Location: Alpine/Campo Status: Non

• Exempt Posted : 2026 Closing Date : TBD Compensation : $21.00 - $30.21/hr.
• DOE Grant : N/A Hours : Full time, Monday-Friday, 8:00AM-4:30PM. GENERAL STATEMENT OF RESPONSIBILITIES: Normal 0 false false false false EN-US JA AR-SA Under the direct supervision of the Health Information Management Director initiates referral process for all patients referred by SIHC providers to healthcare specialty providers for medical, dental, and behavioral health services. Assists in resolving pre-certification, registration, and case management concerns prior to patients’ appointments. Tracks the progress of all referrals to ensure that referral appointments are kept. Works cooperatively with Medical, Dental, behavioral health, and Health Information Management Department to maintain updated records of all referrals. Maintains and updates SIHC referral tracking system. Works in conjunction with the Billing Department, insurance carriers,, and community health systems to assist patients in obtaining appropriate options and funding for specialty care. Position will provide referral services for both Alpine and Campo clinics for Medical, Dental, and Behavioral Health. In addition, the Purchased Referred Care (PRC)/Referral Specialist administers, and coordinates services related to the Purchased Referred Care program. This role ensures eligible patients receive authorized specialty and hospital services through appropriate funding sources, while maintaining compliance with PRC guidelines, documentation requirements, and confidentiality standards SPECIFIC DUTIES AND RESPONSIBILITIES:

1. Process referrals daily while maintaining workflow quality, accuracy, timeliness, and compliance with referral policies.
2. Contact patients for every referral and document all patient communication in the EHR, including preferred specialty location and insurance network.
3. Coordinate referrals within appropriate specialist networks to minimize redirects and delays in care.
4. Acknowledge EHR Inbox action items and tasks within 24–48 hours and complete tasks within required timelines or escalate barriers.
5. Process routine referrals within fourteen (14) business days and STAT referrals within three (3) business days.
6. Maintain ongoing tracking and documentation of referrals to promote team awareness and patient safety.
7. Review referral requests generated by primary care providers for completeness and accuracy.
8. Update SIHC’s referral tracking systems in cooperation with Health Information Management to ensure specialty reports are received timely.
9. Assemble, review, and forward complete medical records to appropriate specialty providers.
10. Contact specialists and insurance companies to ensure prior authorization requirements are met and provide necessary clinical information.
11. Educate patients regarding referral guidelines, expectations, and specialist location information.
12. Review denied or rejected referral requests and initiated peer to peer reviews with insurance and SIHC provider when appropriate.
13. Work closely with Patient Advocates, Case management Team and Community Health Representatives to ensure patients can access specialty services.
14. Send appointment reminders via mail, email or patient portal notifications.
15. Attend training and seminars related to managed care, referral guidelines, and insurance updates.
16. Maintain strict compliance with HIPAA confidentiality requirements.
17. Answer telephone inquiries related to referrals and provided excellent customer service.
18. Ability to work a flexible schedule, multitask, and function in a fast-paced environment. PRC Duties:
19. Performs Purchased/Referred Care (PRC) functions including eligibility review and PRC request and claims processing.
20. Meet established productivity, accuracy, and timeliness standards by processing PRC claims.
21. Clean PRC claims include a mix of reimbursement methodologies, including: a. Medicare-like reimbursement rates b. Coordination of benefits (EOB) and insurance deductible application c. CMS/Web Pricer calculations d. Contracted reimbursement amounts
22. Process clean PRC claims end-to-end, including receipt, review, repricing, payment processing, and issuance of payment to the contracted facility, in accordance with PRC policies, payer requirements, and applicable federal and tribal regulations.
23. Process, track, and monitor PRC cases from authorization through outcome.
24. Process claims which include a variety of reimbursement methodologies, such as: Medicare-like reimbursement rates Coordination of benefits (EOB) and insurance deductible, CMS/Web Pricer calculations and Contracted reimbursement amounts
25. Maintain a comprehensive follow-up system for all PRC cases and payments.
26. Enter PRC invoices and claims into the PRC tracking system in a timely manner.
27. Coordinate with medical, dental, and behavioral health facilities related to PRC services.
28. Verify insurance and third-party payer eligibility and payer-of-last-resort requirements.
29. Collect and maintain complete documentation from healthcare providers.
30. Ensure patient health records are current and accurately reflect PRC services.
31. Identify PRC cases that meet Catastrophic Health Emergency Fund (CHEF) criteria.
32. Prepare and submit CHEF cases in accordance with Indian Health Service (IHS) guidelines, ensuring all required documentation is complete, accurate, and submitted within established timelines.
33. Educate patients about PRC eligibility, benefits, rights, and responsibilities.
34. Direct patients to Health Coverage Enrollment Aide (HCEA) team who will help with alternative resource applications and documentation needs.
35. Maintain strict compliance with HIPAA and confidentiality standards.
36. Attend PRC-related training and remain current with program updates.
37. Provide professional customer service and address patient concerns.
38. Complies with all SIHC policies & procedures.
39. Ability to work flexible schedule may be required based on need.
40. Perform other related duties as assigned.

QUALIFICATIONS

Education/Experience: Must possess a High School diploma or GED certificate. Must have two years of medical office experience . Knowledge of Healthcare Insurance authorization requirements and systems required. Medical Assistant certification and experience preferred. Must have strong customer service focus with effective verbal and communication skills.

Must be highly organized, detailed oriented and a team player. Must be at least 18 years of age. Education, training or experience which complements the knowledge and skills stated above are desirable but does not substitute for minimum requirements as stated. License: A valid driver’s license is required at the time of appointment and must be maintained throughout employment.

Applicants must be insurable under SIHC vehicle insurance policy at the time of hire and throughout employment. Certifications and/or licenses appropriate to the positions required in education and profession must also be valid and maintained. Character : Applicants must have a reputation for honesty and trustworthiness.

Must be responsible and able to exercise good judgment, accept administrative supervision, pay attention to detail, follow instructions, including the ability to interact effectively and communicate with people in a professional and courteous manner. Must be highly confidential and work as a team with other staff. Applicants should be sensitive to client’s needs.

Skills : Strong team building, interpersonal, and organizational skills. Ability to establish and maintain effective peer relationships with coworkers within the Department, clinic-wide, and the public. Must be able to express ideas clearly, concisely, address audiences effectively, and exercise balanced judgment in evaluating situations and making decisions.

Willing to be part of a team and cooperate in accomplishing department goals and objectives. Ability to prioritize, meet deadlines, take initiative, be proactive, and function in a rapidly changing environment. Ability to work with people of all social and ethnic backgrounds, resolves conflicts, negotiates situations, and facilitates consensus.

Physical and Personal Requirements : Normal clinic/office environment. Sit or stand for long periods of time. Reach, bend, climb, stoop, lift up to 25 lbs. repetitive hand movement; use and view PC. Reliable transportation and car insurance as required by the state. Travel as needed. Compliance : Each employee plays a key role in creating a compliance culture at SIHC.

Employees are expected to learn and comply with all SIHC policies and procedures. One must have the ability to understand the implications and complexities of all compliance policies. Participation in all compliance training is mandatory and generally has a heightened awareness of policies and regulations that are specific to one’s department and position.

All SIHC employees are expected to report violations or suspected violations of compliance policies or regulations. Other: Applicants must successfully pass pre-screening, including a tuberculin skin test or x-ray and a blood/urine drug screening test. Health must be adequate to perform all duties of the position. Applicant must complete SIHC Application and Authorization Form, both must be submitted to Human Resources prior to the close date indicated.

INDIAN PREFERENCE : INDIAN PREFERENCE : In the filling of any SIHC job vacancy, preference may be given to qualified Native American Indians, pursuant to the Indian Preference Hiring Act, 25 USC 472, unless other laws require the filling of a vacancy without regard to Indian preference (e.g. Public Law (P.L.) 94-437, “Indian Health Care Improvement Act (IHCIA).

To receive Indian preference for any SIHC position, the applicant must be enrolled, or be eligible for enrollment, as an American Indian with their Tribe, or must be certified as an American Indian from the designated Tribal Representative. Applicants claiming Indian preference must attach verification of their claim to the SIHC application, including Certification of form BIA-4432, which is available from the SIHC Human Resources Department.

If verification is not or cannot be verified, the applicant will not receive Indian preference for purposes of the interview.