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CONTACT REPRESENTATIVE
G S-0962-06

I. INTRODUCTION:
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 Specialist.

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 availability allow.

Perform other related duties as assigned.

III. FACTORS:

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 benefits.

In addition, the incumbent must have knowledge and proficiency in the following areas:

  1. Use of allotments, object, sub-object and class coding required by Navajo Area Office (N A O) financial management practices.
  2. Basic knowledge of medical terminology and medical care practices and procedures.
  3. C P T / I C D - 9 coding.
  4. I H S fiscal accountability.
  5. Typing and computer skills.
  6. Alternate resources (County, State, and Tribal health programs, other related agencies,programs and procedures, private insurance).
  7. Interviewing skills and the ability to establish rapport with patients and provide education.
  8. The ability to speak Navajo fluently is a preferred qualifier for this position, but not absolutely required.
  9. The ability to maintain good public relations and interdepartmental relations.
  10. Effective communication skills over the phone and in person.
  11. vaThe ability to maintain or establish registers of eligible patients in varied programs (for example, dialysis).
  12. Understand and comply with the requirements of the Privacy Act, maintaining confidentiality of patient information.
  13. Demonstrate a willingness to learn and to share information with others.
  14. 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 unclear applications.

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:

  1. As executors of existing contracts;
  2. in the acquisition of health care services;
  3. for eligibility determination;
  4. for decision of payment;
  5. in the appeal process;
  6. 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 center.

Factor 9 – Work Environment:
Work is normally performed in an office setting that is adequately lighted, heated, and ventilated.