Program Manager - Purchased/Referred Care

COWLITZ INDIAN TRIBE•Longview, WA

5d•Onsite

About The Position

Provides strategic, administrative, and operational leadership for the Tribe’s Purchased/Referred Care (PRC) program, ensuring eligible patients receive timely, culturally responsive access to medically necessary services not available within the Cowlitz Indian Tribe Health & Human Services (CITHHS) department. Ensures compliance with federal regulations, Tribal policies, and funding requirements while promoting program efficiency, fiscal stewardship, and a high‑quality patient experience. Performs difficult and complex assignments that encompass a variety of program activities, assisting in program development, management, operation, evaluation, and annual budget planning of the comprehensive PRC Program. Oversees all daily program operations, including eligibility determination, medical priority review, authorization processes, case management oversight, and vendor relations. Maintains responsibility for budget oversight, expenditure monitoring, and the development and implementation of program policies and procedures. Adheres to HIPAA and confidentiality requirements. Honors and represents the mission, vision, and values of the Cowlitz Indian Tribe and of the HHS department. This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Requirements

Bachelor's degree in Healthcare Administration or related field.
Five years of related experience in contract health, healthcare administration, or related field.
Two years of work experience in a supervisory capacity.
A combination of relevant education and related work experience may be considered.
A valid driver’s license is required when driving vehicles for work-related purposes.
Must be able to successfully pass a background screening/investigation according to the established requirements below.
Pre-employment drug screen.
Reference checks, education, and employment verification.
Federal, state, and/or tribal criminal history and sanction checks, including fingerprint verification.
Has not been found guilty of, charged with, received a deferred sentence, received a conditional discharge of, or entered a plea of not contest to, or entered a plea of guilty to any one felony or misdemeanor crimes of violence, sexual assault, molestation, exploitation or sexual contact; prostitution; or crimes committed against person(s) or children.
Knowledge of IHS PRC regulations, eligibility criteria, and medical priority systems.
Knowledge of traditional form of government and tribal customs and traditions.
Knowledge of business English, proper spelling, grammar, punctuation, and basic arithmetic.
Knowledge of medical terminology, referral workflows, and health insurance coordination.
Knowledge of policies and procedures related to HIPAA, Medicare, Medicaid, and insurance programs.
Knowledge and ability to apply 42 CFR Part 136 regulations.
Knowledge of office functions, procedures, and policies.
Skill in leadership and supervisory skills, including staff development and performance management.
Skill in strong conflict‑resolution and de‑escalation skills, including the ability to address patient complaints, explain PRC determinations, and manage appeals or denials with professionalism, clarity, and cultural sensitivity
Skill in operating various word-processing, spreadsheet, and database software programs in a Windows environment, including electronic health care systems.
Skill in treating internal and external customers with tact, courtesy, and respect.
Ability to make decisions absent personal or familial basis.
Ability to maintain confidentiality.
Ability to interact and maintain good working relationships with individuals of varying social and cultural backgrounds.
Ability to communicate efficiently and effectively both verbally and in writing.
Ability to handle multiple tasks and meet deadlines.
Ability to exercise independent judgment.

Nice To Haves

Experience working in Tribal health systems or Indian Health Service strongly preferred.
Knowledge of patient registration and healthcare front office preferred.
Knowledge of the Epic OCHIN Electronic Health Record and Nivonyx systems.
Knowledge of tribal health systems, Indian Health Service (IHS) structure, and the unique role of PRC within tribal communities.

Responsibilities

Supervises PRC staff; provides coaching, counseling, training, and feedback to employees; assigns, reviews, and delegates work and job responsibilities to designated staff.
Hires, evaluates, disciplines, and develops professional and support staff.
Hosts regular staff meetings to ensure communication among staff regarding department-related activities.
Ensures the PRC program operates in accordance with applicable federal guidelines and laws.
Conducts regular audit of member eligibility under the provisions of Tribal/Federal rules.
Monitors all severe health care claims that may meet the spending levels and qualify for the Catastrophic Health Emergency Fund (CHEF).
Serves as the liaison between Indian Health Service and the program for CHEF claims.
Ensures that there is a mechanism for tracking the Washington State Spenddown program.
Keeps leadership and other departments informed of the status of program activities by attending meetings and submitting reports; prepares monthly reports to Executive Leadership and Indian Health Service, as required.
Reviews medical claims to ensure that claims are paid at Medicare-like rates.
Authorizes medical, dental, and vision services for eligible medical beneficiaries and maintains records of all services purchased and payments made.
Assists clients in applying for and accessing alternate services and resources through state, federal, or tribal programs.
Contributes to departmental effectiveness by identifying short-term and long-range issues and goals that must be addressed; providing information and commentary pertinent to deliberations; recommending options and courses of action; implementing directives.
Achieves financial objectives by managing the allocation of funds to the PRC program, including expenditure monitoring and cost‑containment strategies.
Maintains professional and technical knowledge by conducting research, attending seminars, educational workshops, classes, and conferences; reviewing professional publications; establishing networks; participating in professional societies; and conferring with representatives of contracting agencies and related organizations.
Develops and implements PRC policies and procedures.
Resolves complex PRC issues, appeals, and escalated patient concerns.
Ensures that all policies developed are in accordance with PRC regulations in 42 CFR Part 136.
Ensures that all required training is completed for self and staff.
Contributes to a team effort and accomplishes related results as required.
Performs other duties as assigned.