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Contact Representative 218190
(C H S Patient Benefits Coordinator)
This position is located in the Contract Health Services Branch,
Administrative Support Services (C H S) Division, of the Tuba City
Indian Medical Center (T C I M C), Tuba City, Arizona. The primary
purpose of this position is to identify patients with eligibility
for alternate resources, assisting them with the enrollment process,
act ad advocates for Indian patients in the effective utilization
of alternate resources, and act as liaisons between the Service
Unit-Contract Health Services Branch and Non-I H S providers and
II. MAJOR DUTIES AND RESPONSIBLITIES
25% Works closely with facility staff to identify all alternate
resources available. Assist patients in application for use of
alternate resources. Assist patients in establishing and verifying
eligibility for alternate resources, the incumbent must work closely
with the local and regional Social Security Administration Office,
Tribal Offices, Community Department of Welfare or Human Resources,
Department of Social Services, State Medical Assistance Office
and other appropriate agencies.
20% Defines alternate resources available to patients under the
Contract Health Services (C H S) Program. Independently determines
patient eligibility for Medicare, New Mexico and Utah State Medicaid,
Arizona Health Care Cost Containment System (A H C C C S), Department
of Veterans Affairs, Bureau of Employment Compensation, Third Party
Liability, Worker’s Compensation, Children’s Special
Health Services Aid to Families with Dependent Children, Vocational
Rehabilitation, Fragile/Crippled Children, private insurance, state
programs and any other applicable resources. Contacts alternate
resources agencies through telephone, correspondence and personal
visits to ensure maximum utilization. Conducts personal interviews
with patient and/or family member to determine potential eligibility
for any alternate resources.
15% Provides information on rights and benefits of alternate resources
and tactfully advises patients of non-payment or denial of claims.
If denials or other rejection of alternate resources occur, incumbent
will intervene on patient’s behalf in disputing and debating
the denial by the third party sources. Works closely with providers
ensuring that all referrals to non-I H S facilities are within
medical priority and patients are processed with C H S procedures.
15% Follows up on all pending applications and works closely with
families and agencies to that the patient is not discriminated
against because the are I H S beneficiaries. Performs a variety
of patient representative functions including completion of applications
for alternate resources, making home/hospital visits to interview
patients, arranges for transportation of patients to the Department
of Health and Human Services, Social Security Administration Offices
and/or interpreting alternate resources rules and regulations for
10% Participates in Quality Assurance/Utilization Review by preparing
weekly patient log and conducting weekly C H S Review Committee
5% Determines patient eligibility for care under the C H S program.
This requires the application of C H S rules and regulations on
contract health service delivery areas, geographical facility proximity,
tribal membership, residence, close social and economic ties, and
students and transients status. The determination of patient eligibility
is a prerequisite to authorization of funds and requires the making
of accurate and independent decisions for the provision or denial
of payment for services based upon eligibility criteria.
5% Determines the priority for services provided under the C H
S program based upon Area-wide medical priorities established for
relative medical needs. This determination requires compliance
with such priorities in order to ensure that authorization processed
payments fall within those established priorities.
5% Performs and provides continuous research and updating of information
involving changes in rules and regulations for alternate resources.
Performs other related duties as assigned.
III. F E S FACTORS
Factor 1, Knowledge Required by the Position
Knowledge of all Contract Health Services program rules, regulations,
goals and objectives; including program operations, priorities
and goals of various Alternate Resources programs.
Ability to keep abreast of current changes in regulations and
policies on Alternate Resources eligibility, medical terminology,
Contract Health Services program regulations and financial coding.
A working knowledge of various third party resources (Medicare,
Medicaid, Social Security Administration, County D H S Office,
Tribal Programs, and other related agencies) to include established
procedures, required forms, etcetera, associates with the various
Alternate Resources programs, and how it relates to Contract Health
Practical knowledge of medical terminology and an understanding
of I C D - 9 - C M and C P T Coding systems.
Knowledge of and the ability to apply Contract Health Services
Regulations, C F R 42-36, C Alternate Resources regulations, P
L 94-437, Title I V of Indian Health Care Improvement Act, I H
S Policy and Regulations on Alternate Resources, C F R 42-36.21(A)
and 23(F), and P L 99-272, Federal Medical Care Cost Recovery Act.
Factor 2, Supervisory Controls
The incumbent works under the general supervision of the Contract
Health Services Supervisor. The supervisor provides general guidance
and advice, and suggests techniques for handling unusual or nonrecurring
situations, which have no clear precedents. The incumbent plans
and carries work assignments utilizing successive steps, and handles
problems and minor deviations in accordance with instructions,
hospital and/or Contract Health Services policies and procedures.
Factor 3, Guidelines
A number of substantive Contract Health Services regulations,
policies and procedures are utilized from the state, federal, and
agency levels. The incumbent uses judgment in locating and selecting
the most appropriate guidelines, reference or procedure for application,
and when making minor guideline deviations to adapt to specific
issues or cases.
Factor 4, Complexity
The work involves working with various programs that cover several
surrounding states with health insurance programs that have different
benefits, deductibles, and/or eligibility requirements. The work
involves establishing the eligibility of patients, with outside
agencies officials who may be uncooperative and to assist in resolving
Factor 5, Scope and Effect
The purpose of work is to assure maximum utilization of all available
alternate resources and contractor contracts/agreements, for payment
of medical services provided by I H S beneficiaries, by maintaining
a comprehensive Alternate Resources/C H S eligibility determination
process (42 C F R 36.12 and 36.23). Timely management of authorizing
documents, accurate and courteous patient intake/out-take, and
good public relations with providers affects the ability of the
Service Unit to provide quality patient care and program fund control.
The successful effort of the incumbent directly affects N A I H
S ability to meet program and compliance requirements.
Factor 6, Personal Contacts
Contacts are with patients, employees, state and local welfare
agencies, health insurance carriers, fiscal intermediaries, etc.
Other contacts include Bureau of Indian Affairs (B I A), Department
of Veterans Affairs, Social Security Administration, State Vocational
Rehabilitation Offices, County D S S Offices, Services for the
Blind, Children’s Special Health Services and Area Office
staff who are assigned to alternate resources.
Factor 7, Purpose of Contacts
The purpose of contacts is to act as an advocate for patients
in their dealings with local, state, and federal agencies as well
as with miscellaneous health care organizations that may impact
their eligibility for alternate resources. Acts as liaison between
Service Unit C H S Branch and Non- I H S providers/facilities where
T C I M C patients have been referred.
Factor 8, Physical Demands
The work is primarily sedentary, with some bending, walking, standing
and carrying of patient records and light supplies. No unusual
physical demands are required.
Factor 9, Work Environment
Work is performed in an office or clinical inpatient/outpatient
setting. Patients may be uncooperative in divulging required information
resulting in undue stress.
Other Significant Factors
The Privacy Act of 1974 mandates that the incumbent shall maintain
complete confidentiality of all administrative, medical and personnel
records and all other pertinent information that comes to his/her
attention or knowledge. The privacy Cat carries both civil and
criminal penalties for unlawful disclosure of records. Violations
of such confidentiality shall be cause for adverse action.
Incumbent may be required to drive a government vehicle in the
performance of duties.
THIS POSITION IS DESIGNATED AN INDIAN HEALTH SERVICE CHILD CARE WORKER POSITION
COVERED BY P. L. 101-630 AND 101-647.