What are the responsibilities and job description for the Patient Benefits Coordinator position at Kewa Pueblo Health Corporation kphc?
Patient Benefits Coordinator
Department: HIMs
Reports to: Director of HIMs
FLSA Status: Non-Exempt
Type of Position: Full-Time
Revised Date: 11/04/2022
MISSION & VISION STATEMENT:
The Kewa Pueblo Health Corporation (KPHC) is established for the purposes of carrying out the vision and mission of the Santo Domingo Health Center (SDHC). The MISSION of KPHC is: “ENSURING HEALTH & WELLNESS THROUGH EXCELLENCE IN HEALTHCARE WITH RESPECT FOR CULTURE” and the VISION OF KPHC is: “HEALTHY PEOPLE, HEALTHY COMMUNITY, and HEALTHY LIFESTYLE”.
POSITION PURPOSE:
The Patient Benefits Coordinator determines eligibility for alternate resources using established criteria, ensuring full entitlement to alternate resources and acts as an advocate for patients in order to utilize alternate resources effectively. Assures the identification of patients who are eligible for alternate resources and assists parties with the enrollment process.
PERFOMANCE EXPECTATIONS:
In performance of their respective tasks and duties all employees of the Kewa Pueblo Health Center are expected to conform to the following:
- Uphold all principles of confidentiality and patient care to the fullest extent.
- Adhere to all professional and ethical behavior standards of the healthcare industry.
- Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
- Possess cultural awareness and sensitivity.
- Maintain a current insurable driver’s license.
- Comply with all Kewa Pueblo Health Corporation and Santo Domingo Health Center policies and procedures, as well
ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES:
Acts as an advocate for patient in the effective utilization of alternate resources such as Medicare, Medicaid, Department of Veterans Affairs (DVA), Third Party Payers, Children’s Rehabilitative Services, Temporary Assistance for Needy Families (TANF), New Mexico Kids Care programs, Worker’s Compensation, etc.
Educates Patient Registration staff, other Health Center staff, and patients on alternate resources that are available.
Interprets regulations, policies and procedures established by alternate resource agencies such as those listed above.
Provides a full range of services related to PRC (Purchase Referred Care), business office, medical records and clinic administration.
Determines alternate resources available to patients and verifies eligibility by contacting the nearest Social Security Administration (SSA), State Medical Assistance Office and private insurance entities to verify the eligibility of patients. Establishes eligibility of potential Medicare eligible clients by working with the Social Security Administration (SSA). Acts as an advocate for patient in the effective utilization of alternate resources such as Medicare, Medicaid, Department of Veterans Affairs (DVA), Third Party Payers, Children’s Rehabilitative Services, Temporary Assistance for Needy Families (TANF), New Mexico Kids Care programs, Worker’s Compensation, etc.
Educates Patient Registration staff, other Health Center staff, and patients on alternate resources that are available.
Interprets regulations, policies and procedures established by alternate resource agencies such as those listed above.
Provides a full range of services related to PRC (Purchase Referred Care), business office, medical records and clinic administration.
Determines alternate resources available to patients and verifies eligibility by contacting the nearest Social Security Administration (SSA), State Medical Assistance Office and private insurance entities to verify the eligibility of patients. Establishes eligibility of potential Medicare eligible clients by working with the Social Security Administration (SSA) on both the local and regional levels. Works closely with local County Department of Medical Assistance and Tribal Offices to establish eligibility for Medicaid, TANF, Supplemental Social Security Income (SSI), etc.
Interviews all patients eligible for Medicare and Medicaid benefits to ensure they understand their benefits.
Assists families and individuals in applying for and utilizing alternate resources.
Works closely with various disciplines such as Discharge Planning, Utilization Review, Social Services, etc., to coordinate medical care services; obtains required authorizations or concurrent reviews and has the ability to understand and explain billing methodology and collections for KPHC.
Ensures timely submission and accuracy of alternate resource applications and that follow-up is conducted within the established timeframes to meet eligibility requirements. Works closely with families and agencies to ensure that patient is not discriminated against.
Provides information on rights and benefits of resources and tactfully advise patients of non-payment or denial of claim.
Disseminate information through proper channels in accordance with established procedures and performs other general clerical tasks necessary in carrying out patient appointment functions.
Obtains from the patient, proof of tribal enrollment for medical eligibility. Maintains sufficient health records forms, authorizations or clinic information, eligibility forms and standard forms explaining the patient's rights under the Privacy Act and HIPAA.
Maintains a current checking system on each patient receiving medical care from the Health Center. This consists of contacting various Federal, State and County agencies to verify current eligibility for third party health insurance and their identifying numbers.
Prepares and compiles the authorization for release of medical information, assignment of benefits and pre-certification. Gathers and compiles information needed to determine benefits or benefits related health care services for all third party billing purposes and processes.
Performs daily interviews to obtain specific demographic and insurance information in a diplomatic and confidential manner.
Plans and carries out the work of the office and handles problems and deviations in accordance with established instructions, priorities, policies, commitments and program goals of the supervisor and accepted practices in the occupation.
Provide technical PRC information and guidance on all inquiries. Ensures prompt follow up with appropriate personnel and vendors maintaining strict confidentiality.
All HIMS staff will be cross trained in order to provide assistance in Patient Registration, Patient Benefits Coordination, and Medical Records. Knowledge of various types of health policies and types of coverage, terminal digit filing systems, answering phones preferred but not required. Prepares routine correspondence when appropriate to patients, and providers.
- Performs all other duties as assigned.
MINIMUM MANDATORY QUALIFICATIONS:
Education:
- High School Diploma or GED equivalent.
Experience:
- At least one year experience in providing eligibility services. This experience would need to include skills such as, interviewing patients, determining eligibility for various types of resource benefits, Third Party billing, Medicare, Medicaid, etc., verifying insurance information and utilizing NextGen.
Mandatory Knowledge, Skills, Abilities and Other Qualifications:
Excellent verbal and written communication skills.
Ability to perform the essential duties, functions and responsibilities as detailed above.
Knowledge of advanced principle and practices relating to the entire KPHC health care delivery systems, Business Office functions, policies, procedures, priorities and goals.
Working knowledge of the various Third Party resources (Medicare, Medicaid, Social Security Administration, County DHS office, Tribal Programs, and other related agencies). Ability to keep abreast of current changes in policies, regulations on alternate resources eligibility. Ability to interpret rules and regulations for alternate resources for patient s and doing continuous research and updating of information involving changes in rules, regulations and income guidelines.
Knowledge of established procedures, required forms, etc., associated with the various health insurance programs.
Knowledge of Third Party billing systems. Ability to provide clear and concise clarification of the billing aspects and requirements established by the various alternate resource programs, to assure maximum utilization of Third Party reimbursements.
Knowledge of, and the ability to apply, the Alternate Resources regulations; P.L. 94-437, Title IV of Indian Health Care Improvement Act, Indian Health Service Policy and Regulations on Alternate Resources, CFR 42-36.21(A) and 23(F), and P.L. 990272, Federal medical Care Cost Recovery Act.
Knowledge of the NextGen automated data processing system.
Knowledge of oral and written communication and customer service principles, methods, practices and techniques; analytical methods, to include using research tools and statistical analysis; and interpersonal relations practices. Exercises initiative, independence and considerable judgment in interpreting issues and adapting existing practices and precedents.
Ability to organize, prioritize, complete, and track multiple complaints, issues and projects. Prioritizes and reconciles benefit issues through different sources or agencies. Provides feedback in a timely manner.
A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers.
Ability to perform other duties as assigned.
Familiarity with the mandatory reporting requirements under the Indian Child Protection Act, with regards to suspected incidence of child abuse or child neglect.
PREFERRED QUALIFICATIONS:
- Bilingual skills in English and the Keres native language.
- Prior experience working with Indian Health Services (IHS), a Tribe or Tribal Organization.
WORK ENVIRONMENT:
The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. This position may be exposed to certain health risks that are inherent when working within a health center facility.
PHYSICAL DEMANDS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the primary functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk and hear. There may be prolonged periods of sitting, keyboarding, reading, as well as driving or riding in transport vehicles. The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include reading, distance, computer, and color vision. Talking and hearing are essential to communicate with patients, vendors and staff.
MENTAL DEMANDS:
There are a number of deadlines associated with this position. The employee must also multi-task and interact with a wider variety of people on various and, at times, complicated issues.
OTHER:
All employees must uphold all principles of confidentiality and patient care to the fullest extent. This position has access to sensitive information and a breach of these principles will be grounds for immediate termination.
Disclaimer: The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position. It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed.
Applicants will be considered on the basis of whether they meet the minimum mandatory qualifications identified on the position description for the position applied for, including requisite experience, relevant education and possession of required licenses and certifications. Among applicants who meet all minimum mandatory qualification for a position, preference will, to the maximum extent feasible, be granted to qualified Indian applicants.
