This position is located in the Purchased Referred Care at the Crownpoint Healthcare Facility. The purpose of the position is to administer the provision of Purchased Referred Care in compliance with regulatory requirements set forth in the CFR42, Subpart 136, to determine patient's PRC eligibility, defining and interpreting PRC regulations and guidelines and maintaining records. Employee identifies and assists patients who may be eligible for coverage by third party resources.

Duties

Receives notification and referrals for non-IHS and IHS referred care through hard copy or the automated referred care system. Verifies and determines patient's eligibility for Medicare, Medicaid, Private Insurance, VA or other potential alternate resources as appropriate, which are available and accessible to the individual. Researches matters thoroughly based on appropriate regulations or other mandatories prior to rendering work product. Performs prescreening process for potential eligibility and gathers pertinent information utilized to determine PRC eligibility and potentially eligibility for alternative resources. Conducts in-depth face-to-face interview or by telephone with patients and/or families to ensure accurate completion of enrollment application. Ensures that PRC funds are available prior to issuance of obligating documents on behalf of the government. In appeals or denials, employee gathers all necessary information pertinent to the case for the episode of care and completes final review and determination of a reversal and/or affirmed denial. Maintains complete fund control records for health services funds allotted. Reviews incoming claims from providers to determine if authorizations have been issued. Tracks all referrals to non-IHS facilities to include those referrals to other IHS facilities to support the Case Management activities and continuity of care efforts.

Requirements

Qualifications

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. BASIC REQUIREMENT(S): GS-06: One (1) year of specialized experience equivalent to at least the GS-05 grade level GS-07: One (1) year of specialized experience equivalent to at least the GS-06 grade level GS-08: One (1) year of specialized experience equivalent to at least the GS-07 grade level Education generally is not applicable for this series and grade. MINIMUM QUALIFICATIONS: 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: GS-06: Specialized Experience - Apply an extensive body of rules and procedures concerning benefits sufficient to clarify benefit processes and procedures to patients, conduct personal or telephone interview, search records or guidelines, provide full explanations in response to specific inquiries relating to the agency, resolve problems and issues, evaluate the extent of the customers knowledge of the options and choices open to them, explain the requirements placed on them by laws and regulations, review records and contact other offices to learn status of pending actions, the reasons for delays or changes, and what action or additional information is required to resolve the case. GS-07: Specialized Experience - In addition to the above GS-06, ability to apply comprehensive rules, regulations, techniques and procedures sufficient to review the particular circumstances and goals of individuals in order to apply the combination of benefits, services or regulatory requirements that will best meet their needs over a span of time; advise individuals on all aspects of benefits and services that should be considered in deciding the most advantageous choice or action; demonstrate alternative formulas for computing benefits with offsetting advantages and disadvantages; compile and write reports applicable to Business Office and Alternate Resource needs GS-08: Specialized Experience - Perform applicable tasks, described in the GS-7, independently, interprets and follow established business office policies and procedures and in some instances determines appropriate method and approach without consultation with supervisor. 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.

Education

There are no education requirements.

This position has an education requirement. You are strongly encouraged to submit a copy of your transcripts or a list of your courses including titles, credit hours completed, and grades. Unofficial transcripts will be accepted in the application package. Official transcripts will be required from all selectees prior to receiving an official offer.

Only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education may be credited. Applicants can verify accreditation at the following website: https://www.ed.gov/accreditation.

If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address Crownpoint Healthcare Facility PO Box 358 Crownpoint, NM 87313 US
• Name: Navajo Area IHS Human Resources
• Email: [email protected]