Purchased Referred Care Manager

Definition

Under general supervision of the Practice Administrator, the Purchased Referred Care Manager will oversee daily operations and supervise the Purchased/Referred Care (PRC) Coordinators of the River People Health Center, including; managing staff and all function of the organization's PRC program/department. Provide guidance and training to staff in the implementation of a highly functional PRC team. Develop overall policies, procedures, objectives and initiatives of PRC. Establish community-payer relations, compliance, payment and financial analyses to ensure department is effective and properly functioning. Trace numerous metrics and prepare financial and/or operation analyses and reports, an audit procedures to monitor and improve efficient of operations. This job class is treated as FLSA-Exempt.

Essential Functions: Essential functions may include the following tasks, knowledge, skills, abilities, and other characteristics. This list is ILLUSTRATIVE ONLY and is not intended to be a comprehensive list of tasks performed by all positions in this classification.

Examples of Tasks

1. Workflow, Direction and Supervision: Manage all aspects and functions of the PRC program/department to maintain the effectiveness and efficiency.

• Establish and implement guidelines and procedures for effective and efficient processing for authorization and payment of referrals for healthcare services provided to the Salt River Pima-Maricopa Indian Community and within the PRC service delivery area (PRCSDA). Develops, coordinates, and integrates operational plans, policies, and procedures.
• Develops and maintains an active education, training, and PRC awareness program.
• Oversee the supervision of personnel, which includes work allocation, training, and professional development, enforcement of internal procedures and controls, and problem resolution; evaluate performance and make recommendation for personnel actions; motivate employees to achieve peak productivity and performance.
• Provides orientation and training to PRC staff, evaluates work performance, and performs program reviews and annual performance appraisals.
• Develops or updates position descriptions, performance requirements, and policies and procedures as necessary.
• Keeps employees informed of changes in procedures, regulations, and policies affecting service delivery.

2. Organizational Management and Operation : Maintains and operates the PRC Program/Department in accordance with Community and department standards, guidelines, policies and procedures.

• Adapt PRC guidelines and precedents to new or changed situations and apply alternative methods, techniques, and approaches.
• Develop an annual PRC spending plan and budget to maximize the funds allocated each fiscal year; maintain weekly fund status reports to provide the current PRC funding level to the Managed Care Committee.
• Provide guidance on day-to-day services including eligibility determination, authorization and irregular billing information received to RPHC Executive team and PRC staff regarding services with hospitals, clinics, physicians, dentists, and other non-RPHC providers.
• Serves as principal liaison with managers, administrators, and clinic department regarding day-to-day patient referral activities and case management. Ensure that referrals are processed and prioritized in compliance with applicable federal and tribal policies.
• Performs liaison functions with contract health providers, state and local agencies; prepares analytical data, staff reports and memoranda in regard to utilization of PRC resources.
• Maintain up-to-date knowledge on regulatory changes for effective management of the health records system and RPC program and guidelines.
• Responsible for the reporting of Catastrophic Health Emergency Fund (CHEF) cases. Manages and monitors high-cost cases funded though the CHEF program and ensure timely closeout.
• Develop, monitor, and assist with determining provider agreement rates for PRC inpatient and outpatient services. Ensure the processing of Medicare-like rate for services obtained.
• Establish effective communication with the community, patients, providers, healthcare facilities and fiscal intermediary for the scheduling of visits, payments of services and education of RPC program guidelines. Establish and manage appeals process for denied claims.
• Serve as the RPHC's technical authority on the Purchased Referred Care (Contract Health Services) program.

3. Measurement and Evaluation of Performance: Provides oversight to PRC program and staff.

• Review and monitor annual PRC spending plan to maximize the funds allocated each fiscal year.
• Develops statistical data from available reports and other sources to develop, review, approve, and recommend changes to RPHC PRC program operations and budgets.
• Responsible for the direction of PRC case management activities. Supervise PRC case managers.
• Counsels employees as necessary on substandard work and non-compliance with Hospital policies governing conduct and performance.
• Serves as software program liaison of PRC/Management Information Services and Referred Care Information Systems databases.
• Responsible for completing and submitting a variety of budgetary documents and reports required as part of RPHC's budgetary process.
• Represent RPHC in external relationships with other PRC organizations, academic institutions, and governmental agencies.
• Keeps track of transplant patients ensuring treatment plan is obtained for future continuity of care for the patient.

4. Patient Eligibility/Interaction

• Ensures that current eligibility criteria for the RPHC PRC program are followed in the administration of the PRC program. Obtains clarification from healthcare attorney when appropriate.
• Receives and responds to inquiries and makes appropriate referrals of questions pertaining to patient data.
• Routes patients for services when required.

5. Performs other related duties as assigned.

Knowledge, Skills, Abilities and Other Characteristics:

• Knowledge of the culture, customs, traditions, history and government of the Salt River Pima- Maricopa Indian Community.
• Knowledge of health records systems and methodology (e.g., chart assembly, analysis, statistical reporting, etc.) used by health facilities in order to convert medical data for statistical reporting.
• Knowledge of established laws and protocols concerning health record confidentiality in order to protect, control and maintain the integrity of the health record.
• Knowledge of administrative/clerical procedures and systems (e.g. equipment, file management, software programs, etc.) in order to effectively manage the Health records Department.

• Skill in discerning the release of information to protect patient confidentiality.

• Ability to communicate and maintain effective working relationships with healthcare personnel in order to provide quality care.
• Ability to meet and comply with HIPAA/Confidentiality policies and procedures and ability to handle highly confidential and sensitive patient information.
• Ability to manage employees in a high-stress environment.
• Ability to use excellent communication skills, both verbally and in writing.
• Ability to manage multiple and diverse people and tasks in stressful situations.
• Ability to work independently, take initiative and use good judgment.

Minimum Qualifications

Education and Experience: Associate's degree and Seven (7) years progressively responsible relevant experience; or a Bachelor's degree and five (5) years of progressively responsible relevant experience.

• Three (3) years of supervisory/management experience.
• Two (2) years program budget or cuff account experience with the ability to manage and appropriate a budget in excess of $2 million.
• Prior experience working with Indian Health Services (IHS), a Tribe, or Tribal Organization preferred

Equivalency:Any equivalent combination of education and/or experience that would allow the candidate to satisfactorily perform the duties of this position, will be considered.

Underfill Eligibility:An enrolled Community Member whom closely qualifies for the minimum qualifications for a position may be considered for employment under SRPMIC Policy 2-19, Underfill.

Special Requirements

• May be required to work beyond normal work hours including nights, weekends and holidays.
  

• Employees in, and applicants applying for, jobs providing direct services to children are subject to the "Community Code of Ordinances", Chapter 11, "Minors", Article X. "Investigation of Persons Working With Children".

Prior to hire as an employee, applicants will be subject to drug and alcohol testing. Will be required to pass a pre-employment background/fingerprint check.

"SRPMIC is an Equal Opportunity/Affirmative Action Employer" Preference will be given to a qualified : Community Member Veteran, Community Member, Spouse of Community Member, qualified Native American, and then other qualified candidate.

In order to obtain preference, the following is required:1) Qualified Community Member Veteran (DD-214) will be required at the time of application submission 2) Qualified Community Member (must provide Tribal I.D at time of application submission),3) Spouse of a Community Member (Marriage License/certificate and spouse Tribal ID or CIB is required at time of application submission), and 4) Native American (Tribal ID or CIB required at time of application submission).

Documents may be submitted by one of the following methods:

1) attach to application

2) fax (480) 362-5860

3) mail or hand deliver to Human Resources.

Documentation must be received by position closing date.

The IHS/BIA Form-4432 is not accepted .

Your Tribal ID/CIB must be submitted to HR-Recruitment-Two Waters.

Benefits:

The SRPMIC offers a comprehensive benefit package including medical, dental, vision, life, disability insurance, and a 401(k) retirement plan. In addition employees enjoy vacation and sick leave and 13 paid holidays.