Yoeme Managed Care Utilization Manager

Pascua Yaqui Tribe•Tucson, AZ

About The Position

The Yoeme Managed Care Utilization Manager (YMCU) works with the Executive Director of Health to plan, organize, direct, coordinate, and lead personnel and work processes of a multi-million program that serves the Tribal membership residing in Pima and Maricopa counties. Scope of responsibility includes assisting in managing the Commercial Health Self-Insurance Plan -Yoeme Woi Health Plan. The YMCU Manager will have knowledge and familiarity with the key elements of commercial insurance regulations, commercial eligibility, and producing Family Status Reports for Woi members. The incumbent evaluates the programmatic procedures and implements resource programs to assist with the overall program goals of providing a coordinated, comprehensive coordination of benefits. In addition, the incumbent performs the following duties: serves as the Tribal Administrator of the Health-e-Arizona (HEA) site, administers hospital accessibility, ensures compliance with program policies and procedures, determines the use of external providers, and conducts performance evaluations.

Requirements

Knowledge of commercial contracting for Self-Insurance Plan -Yoeme Woi Plan
Knowledge of Blue Cross Blue Shield Health Network
Knowledge of managing Tribal Health Programs
Indian Health Service Programs, policies and procedures.
Community health resources
Medical terminology
Customer service principles
Assess the necessity and urgency of requests for medical services to be provided to members to determine payment for the service.
Monitor and report abnormal trends/variations in healthcare patterns
Promote excellence and professionalism in healthcare quality
ICD-9, ICD-10 and CPT coding guidelines.
Resource and Patient Management System (RPMS) or similar patient information tracking system
Provide clinical review for all requests for home health and physical therapy, making appropriate assessments for approving payment for the service
Maintain a professional approach with confidentiality
Yaqui culture, customs, resources, and traditions, and/or a willingness to learn.
Identify issues and able to provide resolutions
Remain resourceful and calm in emergencies
Monitor and report abnormal trends/variations in healthcare patterns
Promote excellence and professionalism in healthcare quality
Provide clinical review for all requests for home health and physical therapy, making appropriate assessments for approving payment for the service
Maintain a professional approach with confidentiality
Operating a variety of office equipment, including a computer and related software applications
Effective communication and interpersonal skills as applied to interaction with co-workers, supervisor, management, Council members, and the general public.
Ability to sufficiently exchange or convey information and receive verbal and written work instructions.
Bachelor’s degree in public or business administration, or a related field
Two (2) years of Utilization Review (UR) experience
Minimum of two (2) years of supervisory experience
Must possess and maintain a valid Arizona Driver’s License
Must have a current Level 1 Arizona Clearance Card or be able to obtain the Level 1 Arizona Clearance Card within ninety (90) days of hire.

Responsibilities

Provide research, analysis, and recommendations to Health Department Executives which include but are not limited to identifying service improvement procedures, organizational improvements to promote efficiency of service delivery, effective cost control measures, and provide recommendations for positive outcomes.
Assist in managing the Commercial Health Self-Insurance Plan – Yoeme Woi Health Plan, in commercial eligibility and producing Family Status Reports for Woi members.
Assist in providing coordination and communication management and guidance across health care service systems to include Inpatient / Outpatient, Specialty services, Pharmacy, CHEF, and special health projects/initiatives.
Serves as the Tribal Administrator for the Health-e-Arizona (HEA) site.
Assist in Hospital / Clinical Coordination and Discharge planning with Nursing and Clinic Coordinators.
Assist in Prior Authorization review with the Specialty Clinic Coordinator outside of YHP members.
Assist in developing and maintaining sound administrative policies and management protocols including budgets, cost determination, fee setting and collection structure, and financial reports.
Works with the Executive Director, Deputy Director, Medical Director, and others to develop performance improvement targets for the organization's quality, service, and efficiency.
Provides leadership with recommendations for implementing changes targeted at contract policy improvement.
Measures and evaluates attainment of results.
Supervise staff to include prioritizing and assigning work, conducting performance evaluations, ensuring staff are trained and employees follow policies and procedures, maintaining a healthy and safe working environment, and making hiring, termination, and disciplinary recommendations.
Responsible for the daily oversight of the referral department.
Ensure adequate staffing to meet production and quality standards of the program.
Monitor ambulatory data, inquiries from eligibility providers, intermediaries, tribal members, and complex issues.
Monitor communication with provider business offices daily; manage workload distributions for Utilization Review Specialists (URS) and contractor letters.
Review and issue formal response letters to contractors about program member additions, deletions, and changes, send out notifications of member disenrollment, and review the FI pend report.
Assign Health Record Numbers (HRN) to newborns/new program enrollees, sign denial letters for YHP and send Urgent Care letters to members.
Post payments for "I" type purchase orders payable by the Yoeme Health Plan Finance Office and payments for EOBRS that did not process through FI download.
Generate ad hoc reports from RPMS and CHSMIS as required, generate an open document list sent to providers, and access RPMS and RIC modules.
Process and coordinate medical referrals for the Phoenix Indian Medical Center (PIMC) and the Pima County El Rio Health Center, provide healthcare for tribal members in Maricopa and Pima County by scheduling appointments, generating purchase orders, and explaining procedures.
Review medical referrals and claims with assigned committee members; determine medical need, the priority of the request, eligibility, and payer and provide authorization of payment.
Act as an advocate for patients; performs liaison and case management activities between patients and healthcare providers; provides patient education about eligibility, diagnosis, and insurance.
Work closely with the Native American Liaison for AHCCCS ensuring equal treatment for our tribal members.
Monitor contractors to ensure they follow the contract in providing health services to tribal members.
Participate in discharge planning for patients to ensure appropriate services are in place and that the client is being discharged to an appropriate level of care.
Perform other duties of a similar nature or level as requested by the supervisor or director.