What are the responsibilities and job description for the PRC Specialist position at Navajo Health Foundation - Sage Memorial Hospital?
Description
The Purchased Referred Care (PRC) Specialist will receive and respond to requests for information regarding eligibility, prior authorization of services from hospitals, clinics and other health care providers eligible to provide medically necessary services to qualified individuals in the managed health care plan administered by the Navajo Health Foundation/Sage Memorial Hospital (NHF/SMH). This position provides support services to the Purchased Referred Care Department in maintaining a viable program that demonstrates compliance with policy and regulations. This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.
Req Number PUR-25-00001
Position Requirements
Essential Duties & Responsibilities
Sage Memorial Hospital is the only Native American hospital to hold both a license from the Arizona Department of Health Services and Accreditation from The Joint Commission.
The hospital campus is located on private land owned by the Presbyterian Church, within the Navajo Nation Reservation. The organization includes a Critical Access Hospital and outpatient clinic, and an outpatient clinic 28 miles away in Greasewood Springs, AZ.
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.
The Purchased Referred Care (PRC) Specialist will receive and respond to requests for information regarding eligibility, prior authorization of services from hospitals, clinics and other health care providers eligible to provide medically necessary services to qualified individuals in the managed health care plan administered by the Navajo Health Foundation/Sage Memorial Hospital (NHF/SMH). This position provides support services to the Purchased Referred Care Department in maintaining a viable program that demonstrates compliance with policy and regulations. This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.
Req Number PUR-25-00001
Position Requirements
Essential Duties & Responsibilities
- Develop and maintain a working knowledge of Arizona Health Care Cost Containment System (AHCCCS) rules and regulations and the terms and conditions of all NHF/SMH Managed Care contracts.
- Determine third party payer resources and eligibility of individuals for NHF/SMH managed care program using all sources of information available, including the NHF/SMH computer system.
- Receive requests for prior authorization of services and respond according to AHCCCS.
- Complete, maintain, compile and report accurate manual and electronic documentation of all job-related activities in NAIHS system and spreadsheets.
- Consult with immediate supervisor guidance and support in communicating medical management decisions, as needed.
- Assist patient and NHF/SMH staff with arranging prior authorization for non-emergency medical transportation for AHCCCS patients.
- Research patient and provider grievances; compile the information gathered and submit to immediate supervisor for a decision.
- Participate in and attend all required in-services and educational programs to improve and/or learn job-related skills.
- Uphold all principles of confidentiality and patient care according to NHF/SMH policy and procedures.
- Maintain communications with IHS and non-IHS facilities regarding patient referrals.
- Maintain PRC files according to established filing system.
- Receive patient/vendor notifications for medical services.
- Participate in and contribute to NHF/SMH and departmental quality improvement initiatives.
- Gather information on sensitive PRC cases for eligibility, denials, appeals and submit to immediate supervisor for review/approval.
- Provide administrative support to the immediate supervisor.
- Perform other duties as required.
- High School Diploma or General Equivalency Diploma.
- One (1) year of hospital, medical office, or other health care related experience.
- One (1) familiarity with medical terminology, insurance verification, and purchases referred care process.
- Ability to speak the Navajo language (preferred).
- Must be able to successfully pass the Employee Health Program requirements and background investigation.
- Excellent customer relations and telephone skills is a necessity.
- Ability to work in a high stress environment performing tasks requiring attention to detail and precision.
- Ability to work independently and follow tasks given by supervisor.
- Ability to perform work duties in a competent manner with a sense of urgency.
- Ability to speak the Navajo language and/or familiarity with the Navajo Way.
Sage Memorial Hospital is the only Native American hospital to hold both a license from the Arizona Department of Health Services and Accreditation from The Joint Commission.
The hospital campus is located on private land owned by the Presbyterian Church, within the Navajo Nation Reservation. The organization includes a Critical Access Hospital and outpatient clinic, and an outpatient clinic 28 miles away in Greasewood Springs, AZ.
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.