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Contact Representative 218190
(C H S Patient Benefits Coordinator)
G S-0962-07

I. INTRODUCTION
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 facilities.

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 patients.

10% Participates in Quality Assurance/Utilization Review by preparing weekly patient log and conducting weekly C H S Review Committee meetings.

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 Services.

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 controversial issues.

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.

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.