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Contract Health Services Agent

Gardnerville, United States

Position Title

Contract Health Services Agent

Job Type

Full-Time

Classification

Non-Exempt

Grade

NE8 (13.49 - 18.88)

Department

Clinic Medical

Supervisor

Position Summary

Under direct supervision the Contract Health Services Agent is responsible for initiating medical authorizations and documents that are reviewed for patient information and clinical/fiscal data. Maintains confidentiality of all privileged information.
Minimum Qualifications
  • High School Diploma or GED and two years experience in a medical office setting; or equivalent combination of education and experience.

  • Must be able to successfully pass a pre-employment drug/alcohol screen and background investigation.

  • Preference will be given to qualified Native American Indians.

Essential Duties & Responsibilities
  • Determines patient eligibility for care under the Contract Health Services Program in accordance with the Code of Federal Regulations “42 CFR, Part 36 § 36.23”.

  • Identifies and refers patients that are potentially eligible for alternate resources to the Benefits Coordinator.

  • Educates patient on CHS eligibility requirements and program limitations.

  • Determines the priority for services provided under the CHS Program based upon established IHS priority guidelines.

  • Processes medical, mental health, optometry and dental referrals through RPMS/RCIS.

  • Ensures patients are referred to providers within their PPO/HMO network and utilizes CHS contract providers.

  • Commits CHS funds by processing purchase order in the CHS commitment register to ensure the accurate accountability of funds and proper fiscal coding procedures.

  • Closely monitors CHS obligations and expenditures with the objective of keeping within the monthly budget allowance.

  • Prepares denials based on applicable CHS regulations.

  • Monitors activities and records pertaining to the fiscal management of CHS funds.

  • Identifies and refers possible Catastrophic Health Emergency Fund “CHEF” and Third Party Liability Cases to the Fiscal Intermediary department.

  • Notifies the provider as to alternate resource(s) available to the patient to enable the provider to submit the claim to the appropriate alternate resources.

  • Reviews Emergency Room notification for CHS eligibility, notification requirements, priority and coordination of benefits and to estimate associated costs.

  • Participates in Quality Assurance and Utilization Reviews during the CHS Managed Care Committee Meetings.

  • Interfaces with in-house and outside providers to coordinate appointments.

  • Interfaces with patients to discuss details of referral and coordinate appointments.

  • Schedules patient appointments with outside providers.

  • Coordinates transportation request with the transportation department.

  • Ensures that pertinent medical information is forwarded to provider or facility prior to scheduled appointment.

  • Maintains an efficient and effective filing system.

  • Provides technical assistance to management.

  • Explains and interprets regulations and policies to ensure appropriate use of CHS.

  • Develops and implements CHS procedural guides, complies and interprets various alternate resources, references and guides.

  • Answers telephone and personal inquiries regarding CHS eligibility.

  • Compiles information and prepares for submission of periodic and special reports concerning CHS to the Business Office Manager.

  • Performs other duties as required.

Knowledge, Abilities, Skills, and Certifications
  • Knowledge of modern office practices, procedures, and equipment.

  • Knowledge of business English, proper spelling, grammar, punctuation, and basic arithmetic.

  • Knowledge of records management and basic accounting procedures.

  • Knowledge of various insurance benefits and contract health service requirements.

  • Ability to listen intently and skill in working with Native Americans, their families and others.

  • Ability to communicate effectively in the English language both verbally and in writing.

  • Ability to establish and maintain professional relationships with individuals of varying social and cultural backgrounds and with co-workers at all levels.

  • Ability to represent the organization in a professional manner, building respect and confidence.

  • Ability to maintain confidentiality.

  • Ability to handle multiple tasks and meet deadlines.

  • Ability to carry out instructions furnished in verbal or written format.

  • Ability to work independently with minimal supervision.

  • Ability to demonstrate excellence in everything, and continually seek improvement in results.

  • Skill in obtaining exact and precise information from in-depth interviews with Native American patients and other family members to determine possible eligibility for alternate resource funding(s).

  • Skill in operating business computers and office machines, including in a Windows environment, specifically Word, Excel, Access, and presentation software (such as PowerPoint).

Physical Demands
  • While performing the duties of this job, the employee regularly is required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee frequently is required to walk. The employee occasionally is required to stand; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds.

Work Environment
  • Work is generally performed in an office setting with a moderate noise level.

  • The Washoe Tribe of Nevada & California requires a background check of each new hire for employment purposes. Therefore, all conditionally offered positions will be subject to the following:

  • Negative alcohol and drug screen

  • Meet requirements of Public Law 101-630

  • Obtain or possess a valid driver’s license for either the state of Nevada or California within 30 days

  • Must be insurable under the Washoe Tribe’s driving policy