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This position is located at the Winslow Indian Health Center (W I H C); Winslow
Service Unit (W S U) which is a hospital based outpatient care facility. The
W S U also consists of two field health clinics located at Dilkon and Leupp.
The purpose of this position is to administer the Contract Health
Services (C H S ) program as part of the W S U managed care system.
II. MAJOR DUTIES AND RESPONSIBILITIES:
C H S Fund Management: (50%)
Screen all referrals requiring Contract Health Services (C H S) assistance
and ensure that all eligibility factors are met prior to obligating C H S
funds. Obtain necessary medical information for the Supervisory Nurse Specialist
or Clinical Director (C D) to determine medical priority. Make decision of
payment in accordance with the five-day rule and issue Master Delivery Order
Listing (M D O L)/Purchase Order (P O) or denial letter. Establish rapport
with patients and their families in order to assist them with understanding
C H S eligibility and program limitations. Document patient education. Refer
patients to apply for alternate resources when they are potentially eligible
and document efforts to help patients obtain them. Promote fiscally responsible
use of the referral system advocating I H S to I H S referrals first for
patients without alternate resources, contract vendors next, and open market
last. Closely monitor contract health obligation and expenditure rates with
the objective of staying within the Advice of Allowance. Use the Disclosure
Statement Report for obligating by Diagnostic Rate Grouping (D R G) where
possible. Report all Catastrophic Health Emergency Fund (C H E F) cases.
Closely follow C H E F cases to close them out within 120 days of discharge
to maximize potential for 100% or 50% reimbursement after threshold. Review
monthly C O R E accounting system report with the C H S commitment register
to determine the status of open documents and take action as warranted. Report
errors for correcting to W I H C Finance and retransmit any missing documents.
Review the weekly Finalized Pending Reports from Fiscal Intermediary (F I)
and follow up open documents to avoid interest charges (Prompt Payment Act).
Transmit the Document Closure Report (D C R) to Area Finance. Assure reconciliation
procedures/processes are performed. Reconcile the electronic Explanation
of Benefit Report (E O B R) postings in the C H S commitment register with
F I reports. Assure document history records are correct and up to date (late
charges, coding errors, etc.). Maintain familiarity with the contracts of
frequently used vendors. Ensure patient privacy and confidentiality is maintained
in all contacts conducted. Provide special reports concerning C H S as requested
from Area Office. Provide reports as required to the W S U Supervisory Nurse
C H S Case Management: (40%)
Ensure all referrals are entered into the Referred Care Information System
(R C I S). Confirm that all purchase orders are linked to an episode of care.
Ensure accurate data entry in order to obtain meaningful reports. Track all
inpatient and outpatient referrals to non-I H S vendors and to other I H
S facilities to support the service unit’s case management and continuum
of care efforts. Participate in the Case Management Meetings; take minutes
and type the minutes for the record and reporting purposes. Research appeals,
compile required documentation, and submit to the Supervisory Nurse Specialist
findings and recommendations.
Other Duties: (10%)
Act as Arizona Health Care Cost Containment System (A H C C C S) gatekeeper
for non-emergency transportation for our beneficiaries. This involves screening
for A H C C C S benefits, arranging transportation appointments, preparing
and faxing the A H C C C S referrals to A H C C C S for prior authorization,
and to the transportation companies to submit to A H C C C S in order to
receive payment. Attend annual mandatory in-services that pertain to the
department. Attend continuing education/training opportunities as funds or
Perform other related duties as assigned.
Factor 1 – Knowledge Required by the Position:
The Contact Representative position is complex, requiring knowledge and abilities
in many areas. These include knowledge of Contract Health Services (C H S
) programs and regulations; and knowledge of R P M S packages, that is C
H S, R C I S, P C C, and Patient Registration. The incumbent must also be
familiar with use of the State A H C C C S terminal for verification of Medicaid
In addition, the incumbent must have knowledge and proficiency
in the following areas:
- Use of allotments, object, sub-object and class coding required by Navajo
Area Office (N A O) financial management practices.
- Basic knowledge of medical terminology and medical care practices and procedures.
- C P T / I C D - 9 coding.
- I H S fiscal accountability.
- Typing and computer skills.
- Alternate resources (County, State, and Tribal health programs, other related
agencies,programs and procedures, private insurance).
- Interviewing skills and the ability to establish rapport with patients and
- The ability to speak Navajo fluently is a preferred qualifier for this position,
but not absolutely required.
- The ability to maintain good public relations and interdepartmental relations.
- Effective communication skills over the phone and in person.
- vaThe ability to maintain or establish registers of eligible patients in
varied programs (for example, dialysis).
- Understand and comply with the requirements of the Privacy Act, maintaining
confidentiality of patient information.
- Demonstrate a willingness to learn and to share information with others.
- Work both independently and as part of a team.
Factor 2 - Supervisory Controls:
The incumbent works under general supervision of the Supervisory Nurse Specialist.
The incumbent plans and carries out assignments in accordance with accepted
practices in order to meet program goals. Works independently to meet deadlines
and due dates for routine work, reports, and special projects. Follows through
to completion the multiple tasks that this position comprises with minimal
reminders from the Supervisory Nurse Specialist. Resolves most conflicts
or controversial issues that arise. Coordinates work with others. Willing
to train/orient new employees and/or help co-workers with their staff development
needs. Assistance will be provided from the Supervisory Nurse Specialist
for situations that do not have clear precedence or for those assignments
of an unusual nature. The Supervisory Nurse Specialist and peers will review
completed work for accuracy and compliance with established procedures and
requirements on a periodic basis.
Factor 3 – Guidelines:
Guidelines include: Federal regulations, C H S Policies and Procedures, I H
S, Navajo Area I H S and Winslow Service Unit policies and procedures. These
guides are applied using sound judgment. Guides are sometimes adapted for
specific situations or unique cases. The incumbent analyzes case results
and recognizes the need for and recommends changes to sometimes vague and
Factor 4 – Complexity:
The incumbent is responsible for the support of individuals in obtaining alternate
resources, including the education of patients, families, vendors and staff,
and regular follow-up on eligibility. This requires in-depth knowledge of
multiple types of benefit coverage on each client. Basic knowledge of appropriateness
of services rendered and applicable rates must be applied in the administration
of the C H S program process, before issuing purchase orders or denials.
The incumbent performs a full range of clerical, technical, financial, administrative
and public relation functions. These include but are not limited to determining
C H S eligibility; screening for potential alternate resource eligibility;
fiscal accountability procedures; and upholding case management procedures.
Factor 5 – Scope and Effect:
The incumbent promotes case management by assisting patients to obtain needed
quality health care through the referred care system, while controlling unnecessary
expenditures from C H S funds by maximizing the use of alternate resources.
The incumbent follows guidelines in the C H S Manual and Federal Regulations
to administer the following areas:
- As executors of existing contracts;
- in the acquisition of health care services;
- for eligibility determination;
- for decision of payment;
- in the appeal process;
- C H E F case management.
Factor 6 – Personal Contacts:
The incumbent maintains personal contact with: patients and their families;
S U support staff, medical staff and nursing; vendors; representatives from
the fiscal intermediary; N A O contract health consultants, contracts and
grants and finance; local, regional, and federal alternate resource program
advisors and insurers.
Factor 7 – Purpose of Contacts:
To justify, defend or negotiate the delivery of Contract Health Services in
representing the goals, plan and mission of the department/organization,
which includes assisting patients to optimize access to health care within
the constraints of the managed care environment.
Factor 8 - Physical Demands:
The work is mostly sedentary. There is occasional movement throughout the health
Factor 9 – Work Environment:
Work is normally performed in an office setting that is adequately lighted,
heated, and ventilated.