Purchase Referred Care Director

KETCHIKAN INDIAN CORPORATION•Ketchikan, AK

About The Position

The Purchased and Referred Care (PRC) Director is responsible for the management and oversight of the PRC department, ensuring efficient and effective utilization of resources to provide (through referral and PRC funding) comprehensive healthcare services to eligible American Indian and Alaska Native patients. This role includes planning, directing, and coordinating medical referral services, financial operations, and compliance with KIC Tribal Health Clinic and Indian Health Services (IHS) policies and federal regulations The director will provide leadership and guidance for establishing production and work flow systems, setting production and quality standards, defining all operating policies and procedures and claims processing guidelines, coordinating with other departments to ensure that claims payment functionality is optimized to achieve business, operations and reporting objectives, and assuring that goals are met. The director will also participate in Accreditation Association for Ambulatory Health Care (AAAHC) activities and have a complete understanding of CFR42, IHS and PRC regulation and KIC THC PRC policies and procedures.

Requirements

In-depth knowledge/experience in claims processing in a health care setting.
Current knowledge of Medicare-like rate.
Ability to build effective relationships with providers of services.
Superior interpersonal, communication, problem solving and decision-making skills.
Flexibility, initiative, and ability to work as a team player.
Organizational skills to effectively establish work priorities in accordance with objectives and standards.
Familiarity with applicable computer software and databases.
Strong understanding of the IHS PRC program, including policies, procedures, and federal regulations.
Knowledge of healthcare financing, billing, and reimbursement processes.
Excellent organizational and leadership skills.
Strong analytical and problem-solving abilities.
Effective communication and interpersonal skills.
Basic medical knowledge for handling the PRC cases including medical billing and terminology.
Knowledge of Electronic Health Records (EHR) and other relevant clinical and administrative resource tracking programs.
Bachelor’s Degree in health-related or business field.
Three years progressive administrative management experience in third party administration or related field.
A combination of relevant experience, education, and training may substitute for education and experience requirements on a year-for-year basis.

Nice To Haves

Experience in case management.
Experience in community clinic preferred and a strong commitment to multi-disciplinary teamwork.

Responsibilities

Maintains a culturally responsive PRC department through staff training and adhering to policy and procedures while ensuring providers and patients are assisted in getting the care they need, even when it is not covered in the PRC budget.
Coordinate patient/client referrals necessary to fulfill PRC requirements and guidelines.
Ensure patient/client access and signing up to health insurance programs.
Facilitate negotiations and payments on behalf of PRC eligible patients and clients.
Provide accurate records for expenditures relevant to the health program especially the PRC program.
Some travel required for training sessions and conferences.
Monitor PRC operation budget and submit written requests for supplemental PRC funds or justifiable changes if necessary.
Oversee the authorization and processing of medical referrals to external providers.
Monitor and evaluate program effectiveness and make improvements as needed.
Manage the PRC budget, ensuring cost-effective use of funds ensuring KIC is the payer of last resort.
Facilitates PRC Committee to develop, monitor, and enforce financial policies and procedures for PRC and annual operational budget to maximize the PRC funding.
Distribute monthly funds status reports of current PRC funding levels to KIC THC Leadership through the Health Administrator.
Oversee payment processes for services provided by external healthcare entities.
Develop and implement quality assurance programs to monitor service quality and patient outcomes.
Conduct audits and reviews to ensure program integrity and compliance.
Collaborate with healthcare providers, hospitals, and other agencies to coordinate patient care.
Ensure timely access to necessary medical services for patients referred outside of IHS facilities.
Address issues related to service delivery, patient satisfaction, and quality of care.
Provides for PRC onboarding and annual training to providers and support staff.
Current on alternate resources, cost of care locally versus travel
Responsible for reporting potential cases for the Catastrophic Health Emergency Fund (CHEF); work closely with PRC staff to monitor the high-cost cases funded through the CHEF program as established by P.L 100-713 Section 202 and ensures timely close out of all CHEF cases.
Maintain partnership, MOA’s, Agreements, and/or contracts with third-party payor(s) and clearinghouse (s). Monitoring the use of diagnostics tests and referrals for compliance with area and local criteria standards.
Responsible for establishing and maintaining KIC THC PRC department and administrative policies.
Oversees the program planning, development, administration, management, operation, and evaluation of the KIC THC PRC Program.
Ensure current eligibility criteria is followed which requires familiarity with the regulations and ability to explain to providers and PRC program staff. Work with the KIC attorney when appropriate. Prepare necessary correspondence to providers and patients concerning patient PRC eligibility.
Conduct community outreach and education. Ensure patients, private providers, and other agencies understand PRC is the last payor for medical services and funding is available upon meeting eligibility criteria.
Maintain appeal records files in keeping with the appeal process contained in Federal regulations or policies.
Develops and proposes effective department guidelines in keeping with approved Tribal Council Policies and Ordinances.
Performs other duties as assigned.