Referral Coordinator (42303)

Under general supervision of the Purchased Referred Care (PRC) Nurse Manager, the Referral Coordinator assures PRC fiscal accountability working closely with various departments to ensure coordination between the referring PCP and specialist. Responsible for determining PRC eligibility and coordinating specialty medical service for Dilkon Medical Center (DMC) and Winslow Indian Health Care Center (WIHCC) when WIHCC is unable to meet these healthcare needs. Participates and follows PRC policy and guidelines to meet program goals. Upholds the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.

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

Essential Duties & Responsibilities:

• Maintains regular attendance and punctuality.
• Greets visitors, patients, families, staff and physicians. Uses appropriate, professional courtesy for all telephone interactions.
• Screens all cases for Purchased Referred Care eligibility.
• Ensures that all eligibility factors are met prior to obligating PRC funds.
• Obtains necessary medical information for the RN Case Manager or Clinical Director (CD) to determine medical priority.
• Makes timely decision to approve or deny a referred request.
• Monitors progress in improving the referral billing and claim process to close-out open PO’s.
• Assists patients and families in understanding eligibility and program limitations; documents patient education.
• Confirms and is responsible outside consults are faxed for review and scheduling based on medical priority as 1-7 day, 8-30 day and non-urgent referrals.
• Refers patients to Patient Benefits Coordinator (PBC) to apply for alternate resources when they are potentially eligible and documents efforts.
• Promotes fiscally responsible use of the referral system advocating IHS referrals first for patients without alternate resources, contract vendors next, and open market last.
• Monitors contract health obligation and expenditure rates with the objective of staying within the funding perimeters.
• Uses the Disclosure Statement Report for obligating by Diagnostic Rate Grouping (DRG) where possible.
• Maintains familiarity with the contracts or rate quotes of frequently used vendors.
• Provides reports as required by the HSS or PRC Supervisor (backlog report).
• Keeps track of denials for potential AHCCCS eligible and affirms or reverses based on DES decision.
• Responsible for all referrals ensuring they entered accurately into the Referred Care Information System (RCIS) and Electronic Health Record (EHR).
• Verifies that every purchase order is linked to an episode of care, confirms decision of payment is accurate and all denial reasons reflect quality documentation and timeliness.
• Ensures accurate data entry in order to obtain meaningful reports.
• Teaches and trains employees; evaluates program performance, and training needs.
• Reports any high-risk cases or barriers to care to the RN Case Manager.
• Maintains registers of select groups of patients to ensure alternate resources are maximized, patients are not lost to follow up, and that appropriate vendors receive payment (e.g. dialysis, oxygen, PAP rentals).
• Responsible for entering reoccurring obligations, timely, accurately and without reminder.
• Requires completion of tasks or duties assigned by a supervisor.
• Assists with solving computer software and technical issues that may arise.
• Upholds all principles of confidentiality and patient care to the fullest extent.
• Adheres to all WIHCC General Work Rules and Standards of Ethical Conduct.
• Adheres to all professional and ethical behavior standards of the healthcare industry.
• Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
• Responsible for referral tracking utilizing the PRC referred spreadsheet template.
• Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
• Possesses cultural awareness and sensitivity.
• Maintains compliance with all Human Resources requirements.
• Responsible to comply with RCIS training and stay current with PRC updates.
• Performs other duties as assigned.