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Purchased Referred Care (PRC) Coordinator
Purchased Referred Care (PRC) Coordinator in Rapid City, South Dakota at Great Plains Tribal Leaders Health Board Inc
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Job Description
Purchased.Referred.Care.(PRC)Coordinator.fy26.docx
Position Title: Purchase Referred Care Coordinator
Division: Oyate Health Center
Reports To: Purchased Referred Care Manager
Job Summary:
This position is responsible for initiating, tracking, and processing “payer of last resort” health insurance claims
according to United Indian Health Services (UIHS) Contract Health Services (CHS) guidelines. It requires a
thorough knowledge of: Purchased Referred Care services and alternate resources, that may include but is not
limited to private insurance, and Medicare/Medicaid programs; knowledge of alternate resources including the
Affordable Care Act (ACA); knowledge of funds control techniques to account for the funds allotted for the
Purchased/Referred Care services; and knowledge of specialized medical terminology that may include diagnosis
and procedural terms.
Specific duties include, but are not limited to:
- Maintains Contract Health Service files.
- Determines if incoming Contract Health Services referrals are within the UIHS approved priorities.
- Prepare and follow up on Contract Health Services referrals that need medical and dental review.
- Determines if clients meet eligibility requirements, including referral to Alternate Resources for screening
and application if eligible.
- Contact outside providers to set up appointments for approved cases, ask for an estimate of charges, and
notify clients of scheduled appointments. Create purchase orders for eligible approved referrals.
- Communicates and corresponds with outside agencies and clients regarding claim submission.
- Communicates and corresponds with clients/providers regarding status of Contract Health Services claims.
- Communicates and corresponds with UIHS providers to clarify Contract Health Services referrals and
address case status questions.
- Tracks Contract Health Services cases through the processes of appointment, procedural scheduling,
outcome, third party insurance eligibility determination, and final claims payment processing.
- Tracks and submits claim reimbursements through Contract Health Services.
- Prepare and submit Catastrophic Health Emergency Fund (CHEF) cases following guidelines from IHS.
- Notify supervisor of possible pending CHEF cases so they can be reported to the Patient Registration/ Contract Health Services committee.
- Responds to inquiries and requests for PRC services assistance via telephone, written communication, or personal visit. Coordinates these requests and provides consultation to resolve problems or issues. These requests in many instances originate from a variety of sources requiring contact with outside agencies and organizations.
- Must comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPAA).
- Performs related duties.
- Performs the core responsibilities of the position accurately, timely, and in accordance with established standards.
- Maintains regular and reliable attendance consistent with the position’s schedule and operational needs.
- Communicates effectively with internal and external stakeholders as required by the role.
- Adheres to all applicable policies, procedures, and regulatory requirements.
- Utilizes required systems, tools, and technology necessary to perform the job.
- Attends the Managed Care Committee on a weekly basis.
Minimum Qualifications
- High school diploma or equivalent.
- Three (3) years of administrative support experience, including one (1) year of experience working in purchased referred care, sufficient to understand and perform the major duties of the position, and to be able to answer questions and resolve problems. Experience in a health care business office, medical insurance office, social services agency or customer services position is preferred.
- Must successfully pass a criminal and background check, and a pre-employment drug screen.
The GPTCHB is a tribal organization which follows tribal preference laws. It is our policy to give preference to qualified Indian/Tribal candidates over a qualified non-native candidate in hiring decisions, if all other qualifications are equal.
Employment is contingent upon the outcome of all required criminal background checks and pre-employment drug screen.
Compliance with our Employee Health Procedure is a condition of employment. You are required to agree that you will comply with all job-related employee health screening and immunizations prior to your first day of employment. Jobs require that you have documentation that you have completed the following immunizations prior to your first day of employment: MMR (Measles, Mumps and Rubella, Varicella (Chicken Pox), Hepatitis B, Influenza, T-dap (Tetanus - Diphtheria - Pertussis), and COVID-19 vaccination is required.
This position requires the ability to perform the essential functions of the job, with or without reasonable accommodation. Physical demands and work environment may include:
• Primarily sedentary work is performed in an office or administrative setting.
• Requires the ability to sit for extended periods and regularly use standard office equipment such as a computer, keyboard, telephone, and copier.
• Occasional standing, walking, bending, and reaching may be required.
• Ability to lift and carry office materials or supplies up to 25 pounds occasionally.
• Requires manual dexterity and visual acuity for computer use and document review.
• Must be able to read, write, speak, and hear.
• Work is performed primarily in an indoor office or administrative environment.
• The environment involves everyday risks or discomforts that require normal safety precautions typical of office settings, including proper use of office equipment and awareness of trips, falls, and fire regulations.
• The work area is adequately lighted, heated, and ventilated.
• Minimal exposure to hazardous conditions; no routine exposure to clinical, field, or high risk environments.
• Occasional attendance at meetings, training sessions, or events may require travel within the organization's facilities.
The employee must comply with all organizational policies, procedures, and applicable laws and regulations. This position is subject to Native Preference, background checks, health requirements, and other applicable organizational standards.