Program Specialist - Purchased/Referred Care

POSITION TITLE: Program Specialist – Purchased/Referred Care
DEPARTMENT: Purchased/Referred Care (PRC)
LOCATION: Longview, Washington
REPORTS TO: Program Manager, PRC
STATUS: Hourly; Full-Time
WAGE RANGE: $27.15 - $31.25 per hour

CLOSING DATE: Open Until Filled (First Review 8/18/2026)

***If you are an American Indian/Alaska Native and/or a Veteran and would like this to be considered a preference in hiring, please upload documentation with your resume and cover letter. Acceptable documentation includes a Tribal Enrollment card, a letter from your Tribe stating your enrollment, or BIA 4432 and/or DD214.***

Position Summary:

Coordinates Purchased/Referred Care (PRC) services by determining patient eligibility, reviewing and processing referrals and prior authorizations, coordinating access to healthcare services, and processing claims for payment and denials in accordance with Cowlitz Indian Tribe Health & Human Services (CITHHS) policies and procedures and PRC program requirements. Educates members and providers regarding PRC eligibility, alternate resources, and program requirements to ensure timely access to care. Maintains accurate records, protects confidential information (HIPAA), and provides exceptional customer service while supporting the mission, vision, and values of the Cowlitz Indian Tribe.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Authorizes medical, dental, and vision services for eligible medical beneficiaries and maintains records of all services purchased and payments made.
• Assists and educates clients on program registration and enrollment processes, including completing applications, meeting program requirements, and accessing alternate resources.
• Reviews and determines client eligibility for PRC program services and coordinates access to available benefits to ensure clients receive services and resources for which they qualify.
• Maintains billing and payment records, communicates with clients and providers on payment application procedures, claims processing, and status updates.
• Maintains accurate patient records to include eligible data, invoices of all medical bills paid, and referrals.
• Responds to requests for information from vendors concerning payment of bills promptly and in accordance with tribal policies and procedures.
• Participates in training and ongoing program evaluation to ensure PRC program is meeting the needs of clients.
• Provides education to clients, vendors, and staff on PRC policies, appeal processes, alternate resources, and eligibility requirements.
• Processes and monitors prior authorizations; coordinates with patients and providers to obtain required information and follows cases through payment completion.
• Tracks, records, and reports on client and program data as requested.
• Reviews, prepares, and submits Purchased/Referred Care (PRC) claims for payment in accordance with CITHHS regulations,
• Manages incoming telephone and voicemail communications by screening inquiries, determining needs, and routing calls and messages to the appropriate personnel or department.
• Participates in staff meetings as needed.
• Adapts to changes in safety protocols and procedures.
• Completes Information Security System Awareness (ISSA) training as required.
• Contributes to a team effort and accomplishes related results as required.
• Performs other duties as assigned.

Knowledge, Skills, and Abilities:

• Knowledge of traditional forms of government and tribal customs and traditions.
• Knowledge of business English, proper spelling, grammar, punctuation, and basic arithmetic.
• Knowledge of basic medical terminology preferred.
• Knowledge of electronic health records (EHR) and patient registration systems.
• Knowledge of policies and procedures related to HIPAA, Medicare, Medicaid, and insurance programs.
• Skill in operating various word-processing, spreadsheet, and database software programs in a Windows environment, including electronic health care systems.
• Skill in reviewing claims, billing information, payment documentation, and numerical data for accuracy.
• Skill in providing professional, respectful, and culturally appropriate customer service to providers, Tribal members, and community partners.
• Ability to interpret and apply PRC eligibility requirements, policies, regulations, and procedures.
• Ability to review detailed medical, insurance, billing, and claims information for accuracy and completeness.
• Ability to research and resolve discrepancies involving eligibility, referrals, authorizations, claims, and payments.
• Ability to maintain confidentiality.
• Ability to interact and maintain good working relationships with individuals of varying social and cultural backgrounds.
• Ability to carry out instructions furnished in verbal or written format.
• Ability to communicate efficiently and effectively both verbally and in writing.
• Ability to handle multiple tasks and meet deadlines.
• Ability to exercise independent judgment.