This position is located in the Purchased/Referred Care (PRC) at the Rosebud Service Unit in Rosebud, South Dakota. 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.
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-6: One year of specialized experience equivalent to at least the GS-5 grade level. GS-7: One year of specialized experience equivalent to at least the GS-6 grade level. GS-8: One year of specialized experience equivalent to at least the GS-7 grade 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: EXAMPLES OF SPECIALIZED EXPERIENCE GS-6: Provide clerical duties such as making appointments, data entry, maintaining files, and answering phone calls; Conduct interviews in order to determine patient's eligibility for services; Issue medical referrals and denial letters for medical services; Communicate with patients regarding medical bills, claim status, and referrals. GS-7: Assess and educate patients in regard to unique health services and program eligibility; Initiate medical authorizations and denial of service for medical services; Prepare and distribute purchase order authorizations for patient care services and ensure prompt payment; Research vendor claims and purchase orders to provide prompt follow-up; Review incoming claims from providers to determine if authorizations are approved or denied. GS-8: Prepare and distribute purchase order authorizations for patient care services and ensure prompt payment; Conduct comprehensive patient interviews to determine eligibility for alternate health insurance resources; Provide recommendations to patients on the various health care benefit programs and eligibility criteria based on current health care laws and regulation; Conduct extensive research and providing benefit updates involving changes in rules and regulations for alternate resources; Review financial reports for reconciliation with outstanding accounts and progressive payments to ensure accuracy. 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.
Verifies patient's eligibility for Purchased/Referred Care by reviewing documentation regarding eligibility and alternate resources. Receives referrals from physicians and emergency call-ins for Purchased Referred Care; evaluates each case according to current priorities and availability of funds. Assist in preparation, submission and payment processes of purchase orders for services rendered.