This position is located in the Purchase Referred Care Department at an IHS Service Unit. The purpose of the position is to administer the provision of Purchased/Referred Care in compliance with regulatory requirements to determine patient's eligibility, defining and interpreting PRC regulations and guidelines and maintaining records. Employee reports to the departmental supervisor.
To qualify for this position, your resume must state sufficient experience and/or education, to perform the duties of the specific position for which you are applying. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community; social). You will receive credit for all qualifying experience, including volunteer and part time experience. You must clearly identify the duties and responsibilities in each position held and the total number of hours per week. MINIMUM QUALIFICATIONS: GS-06: One (1) year of specialized experience equivalent to the GS-05 grade level. GS-07: One (1) year of specialized experience equivalent to the GS-06 grade level. GS-08: One (1) year of specialized experience equivalent to the GS-07 grade level. Specialized Experience: Experience that equipped the applicant with the particular knowledge, skills, and abilities (KSA's) to perform successfully the duties of the position, and that is typically in or related to the position to be filled. To be creditable, specialized experience must have been equivalent to at least the next lower grade level. Applicants who have the 1 year of appropriate specialized experience are not required by this standard to have general experience, education above the high school level, or any additional specialized experience to meet the minimum qualification requirements. Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Specialized experience at the GS-06 Level: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Working with a health care delivery system or similar system to respond to inquiries from individuals as they relate to the type of health services the medical facility can provide and to solve problems or educate individuals about medical facility health programs and procedures including tasks such as assisting patients in applications for entitlement for health related programs, interviewing patients and or a family member to obtain pertinent and accurate information, research current information involving changes in rules and regulations for alternate resources and determines the eligibility of patients seeking healthcare. Specialized experience at the GS-07 Level: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Work experience that demonstrates knowledge of eligibility requirements for health care benefit programs such as Medicare, Medicaid, Social Security Insurance, and other similar resources to help patients in applying for alternate resources if not directly eligible for health services the medical facility can provide including experience in interviewing clients for information and advising customers on various health care benefits and eligibility based on current health care laws, regulations, policies and procedures. Specialized experience at the GS-08 Level: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Work experience that demonstrates comprehensive knowledge of rights and benefits of multiple alternate resources; advise patients of nonpayment or approval of claim; compile and write reports; contact alternate resources to explore reasons for adverse decision, the possibility of reconsideration, whether there are grounds for appeal; complete contacts independently including review of complex records, reconstruction of involved transactions, analysis of precedent decisions. Time In Grade Federal employees in the competitive service are also subject to the Time-In-Grade Requirements: Merit Promotion (status) candidates must have completed one year of service at the next lower grade level. Time-In-Grade provisions do not apply under the Excepted Service Examining Plan (ESEP). You must meet all qualification requirements within 30 days of the closing date of the announcement.
Receives, enters, and edits all non-IHS and IHS referrals. Verifies and determines patient's eligibility for third party resources. Performs research related to medical documentation, administrative compliance, and inquiries. Conducts in-depth face to face interviews or by telephone to gather pertinent information related to patient care. Ensures PRC funds are available prior to issuance of obligating documents on behalf of the government. Initiates medical authorizations. Gathers all necessary information for appeals or denials. Prepares periodic and special reports.