Purchased/Referred Care (PRC) & Referrals Specialist na Southern Indian Health Council (SIHC)

Job Announcement

Position Title:            Purchased Referred Care (PRC) & Referrals Specialist

Supervised By:         Health Information Management Director

Location:                   Alpine/Campo

Status:                       Non-Exempt

Posted:                      October 1, 2025

Closing Date:            Until Filled 

Compensation:          $21.00 - $30.21/hr. - DOE

Grant:                         N/A

Hours:                        Full Time, Monday-Friday, 8:00AM-4:30PM. 

GENERAL STATEMENT OF RESPONSIBILITIES:

Under the direct supervision of the  Health Information Management Director initiates referral process for all patients referred by SIHC providers to healthcare specialty providers for medical, dental, and behavioral health services. Assists in resolving pre-certification, registration, and case management concerns prior to patients’ appointments. Tracks the progress of all referrals to ensure that referral appointments are kept. Works cooperatively with Medical, Dental, behavioral health, and Health Information Management Department to maintain updated records of all referrals. Maintains and updates SIHC referral tracking system. Works in conjunction with the Billing Department, insurance carriers, social services, and community health systems to assist patients in obtaining appropriate options and funding for specialty care. Position will provide referral services for both Alpine and Campo clinics for Medical, Dental, and Behavioral Health. 

SPECIFIC DUTIES AND RESPONSIBILITIES:

1. Maintains ongoing tracking appropriate documentation on referrals to promote team awareness and ensure patient safety.

2. Review’s referral requests generated by primary care physician.

3. Updates SIHC referral tracking systems in cooperation with Health Information Management to ensure   specialties reports receive in a timely manner Update the information in the referrals tracking system.

4. Process  assembles and review all  medical records information concerning patient’s managed care / for appropriate specialty providers. 

5. Contact the referred entity and insurance companies to ensure prior approval requirements are met. Present necessary medical information such as history, diagnosis and prognosis. Facilitates appointments for patients and requests follow-up information from specialist. Contacts patients if appointment is not kept and assists in rescheduling in a timely .manner

6. Educates patient regarding referral guidelines and expectations as well as policies and provides information about location of specialist’s office or hospital.

7. Reviews rejected requests for procedures or visits and initiates appeal when indicated.

8. Ensure that referrals are addressed in a timely manner. Work closely with Patient Advocates and Community Health Representatives to ensure patients will be able to schedule an appointment with the specialty  providers 

9. Remind patients of scheduled appointments via mail or phone. 

10. Attends seminars or training sessions as appropriate for new managed care or social service programs and/or updates on existing programs. Maintains current knowledge of referral guidelines, databases of active providers, necessary coverage information, and private insurance.

11. Maintain patient confidentiality, know and adhere to all HIPPA regulations.   Mails, faxes, medical records, should be kept confidential and safeguarded at all times.

12. Maintain a 10-12 referrals submission daily  and ensure the accuracy of documents submitted to specialties’ offices.  
13. Addresses patient problems/concerns as may arise. Provide excellent customer service .
14. Answers telephone inquiries on matters relating to referrals.

Complies with SIHC’s policies and procedures Process all Purchased / Referred Care referrals  for patients in this program. Assists with maintenance of patient registries to include:

1. Determines if clients meet Contract Health Services eligibility requirements for the Purchased and Referred Care program.
2. Maintain extensive follow-up system on all Purchased and Referred Care accounts.
3. Work directly with various medical, dental, and behavioral health business offices and other clinical providers referred to by Purchased and Referred Care
4. Arrange transportation for patient/clients to assist them with obtaining necessary documents when applying for an alternative resource.
5. Receive telephone and written inquiries concerning patients admitted to facilities other than IHS facilities.  Secure complete data from medical, dental, and behavioral health providers.
6. Ensure that the patients SIHC chart is up to date with the information on specialist consults/chart notes, labs, hospitalizations, ER visits, and community organizations related to their health. 
7. Tracks Contract Health Services cases through the processes of: appointment, procedural scheduling, outcome, third party insurance eligibility determination.

15. Enter  PRC invoices and claims on the PRC tracking system.

16. Educate patients about PRC program eligibility, benefits, and guidelines

17. Assist patients in understanding their rights and responsibilities within the program

18. Develop and maintain patient education materials and resources

19. Stay up to date on program changes and updates, applying this knowledge to patient education

20. Ability to work a flexible schedule may be required based on need. 

21. Ability to multi-task and work in a fast-paced environment

22. Other duties as assigned

QUALIFICATIONS:

Education/Experience:  Must possess a High School diploma or GED certificate.  Must have Two years of medical office experience  Knowledge of Healthcare Insurance authorization requirements and systems. Medical Assistant certification and experience preferred. Must have strong customer service focus with effective verbal and communication skills. Must be organized and able to manage priorities.

            Must be highly organized, detailed oriented and a team player Must be at least 18 years of age.  Education, training or experience which complements knowledge and skills stated above is desirable but does not substitute for minimum requirements as stated.

License:  A valid California driver’s license is required at the time of appointment and must be maintained throughout employment.

Applicant must be insurable under SIHC vehicle insurance policy at the time of       hire and throughout employment.

Certifications and/or licenses appropriate to the positions required education and profession must also be valid and maintained.

Character:  Applicants must have a reputation for honesty and trustworthiness. Must be responsible and able to exercise good judgment, accept administrative supervision, follow instructions, and exercise a high level of attention to detail, including the ability to interact effectively and communicate with people in a professional and courteous manner. Applicants should be sensitive to clients’ needs. Must be highly confidential.

Physical and Personal Requirements: Normal clinic/office environment. Sit or stand for long periods of time. Reach, bend, climb, stoop, lift up to 25 lbs. repetitive hand movement; use and view PC. Reliable transportation and car insurance as required by the state. Travel as needed.

Compliance: Each employee plays a key role in creating a compliance culture at SIHC. Employees are expected to learn and comply with all SIHC policies and procedures. One must have the ability to understand the implications and complexities of all compliance policies. Participation in all compliance training is mandatory, and generally have a heightened awareness of policies and regulations that are specific to one’s department and position. All SIHC employees are expected to report violations or suspected violations of compliance policies or regulations.

Other:  Applicants must successfully pass a pre-screening, including a tuberculin skin test or x-ray and a blood/urine drug screening test.  Health must be adequate to perform all duties of the position.   Applicant must complete SIHC Application and Authorization Form, both must be submitted to Human Resources prior to the close date indicated.

INDIAN PREFERENCE: 

INDIAN PREFERENCE: In the filling of any SIHC job vacancy, preference may be given to qualified Native American Indians, pursuant to  the Indian Preference Hiring Act, 25 USC 472,  unless other laws require the filling of a vacancy without regard to Indian preference (e.g.   Public Law (P.L.) 94-437, “Indian Health Care Improvement Act (IHCIA).   To receive Indian preference for any SIHC position, the applicant must be enrolled, or be eligible for enrollment, as an American Indian with their Tribe, or must be certified as an American Indian from the designated Tribal Representative. Applicants claiming Indian preference must attach verification of their claim to the SIHC application, including Certification of form BIA-4432, which is available from the SIHC Human Resources Department. If verification is not or cannot be verified, the applicant will not receive Indian preference for purposes of the interview.