PURCHASE REFERRED CARE (PRC) SUPERVISOR

NAVAJO HEALTH FOUNDATION - SAGE MEMORIAL HOSPITAL, INC.•Ganado, AZ

About The Position

This position provides leadership in managing, coordinating, facilitating, and assessing the Purchased Referred Care (PRC) of Sage Memorial Hospital. The incumbent will provide operational direction and oversight, including coordination and distribution of workload. The Purchased Referred Care Supervisor will report directly to the Chief Financial Officer. This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Requirements

Knowledge of the Navajo culture, customs, and traditions.
Knowledge of the theories, principles, practices, and techniques of program planning and evaluation.
Knowledge of supervisory methods and procedures.
Knowledge of principles, practices, and techniques of health care financing, contracting, and administration, including coordination of benefits, medical services contracts, and agreements
Knowledge of applicable federal, state, tribal laws, regulations, and requirements that govern the administration of PRC funds.
Thorough knowledge of Public Law 94-437, Title IV of the Indian Health Care Improvement Act, and Public Law 99-272, the Federal Medical Care Cost Recovery Act.
Knowledge of federal policy and regulation of alternate resources, CFR 42-36.21 (A) and 23 (F).
Thorough knowledge of Purchased Referred Care and the managed care model of healthcare delivery includes utilization review, pre-admission authorization, concurrent review criteria, discharge planning, and medical terminology.
Comprehensive knowledge of alternative resources, such as Medicare, Medicaid, and private insurance, and PRC program eligibility requirements, including knowledge of reimbursable insurance procedures and requirements, including the ability to interpret provisions of individual health plans and group plans.
Knowledge and ability to appropriately utilize, implement, supervise and teach the use of electronic data collection.
Ability to mediate varying views of program requirements and obtain census in accepting concepts, plans, and specifications to meet the needs of the SMH patients.
Ability to develop and maintain effective working relationships with health care personnel of many disciplines, administrators, and official of tribal, federal, state, local, professional, private, public, and voluntary agencies and organizations.
Process strong analytical, writing, and verbal communication skills to effectively interact with State agencies, Indian Health Services, Tribal and urban programs, and an array of staff and individuals from the private sector.
Thorough knowledge of budget and fiscal management concepts to combine and consolidate financial data into useful decision-making information.
Thorough knowledge of the Privacy Act of 1974.
Knowledge of Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA).
Must be familiar with preparing bids and contract documents (including cost estimates and specifications).
Experience with recent versions of word processing and spreadsheet software (e.g., MS Word/Excel/PowerPoint) to generate necessary documents and performs calculations.
Master’s degree in business administration, health care administration, or closely related field
Four (4) years of purchased referred care services experience.
Four (4) years of progressive supervisory & leadership experience.
Valid Driver’s License.
Must be able to successfully pass the Employee Health Program requirements and background investigation.

Nice To Haves

MSN preferred

Responsibilities

Manage the overall Purchased Referred Care (PRC) program.
Maintain the effectiveness and efficiency of the PRC program.
Develops, coordinates, and integrates operational plans, policies, and procedures.
Adapts PRC guidelines and precedents to new or changed situations and applies alternative methods, techniques, and approaches.
Maintains an accurate and current electronic record-keeping system for the PRC program.
Establish effective communication with the community, patients, providers, healthcare facilities, and fiscal intermediary for the scheduling of visits, payment of services, and education of PRC program guidelines.
Develop statistical data from available reports and other sources to develop, review, approve, and recommend changes to SMH PRC program operations and budgets.
Submits monthly status reports of funding to the Executive Committee and Board of Directors, or as requested.
Provide interpretation of guidelines, verification of claims, appropriateness of services, and irregular billing information received, to Administration and PRC staff regarding services with hospital clinics, physicians, dentists, and other non-SMH providers.
Ensures that current eligibility criteria for the SMH PRC program are followed in the administration of the PRC program.
Obtaining clarification from healthcare attorney when appropriate.
Participates in Performance Improvement initiatives to minimize problems and optimize operational efficiency.
Works closely with the business office, providers, and case managers to ensure that all external medical/dental referrals are medically appropriate and within priority.
Responsible for the reporting of Catastrophic Health Emergency Fund (CHEF) cases.
Manages and monitors high-cost cases funded through the CHEF program and ensures timely closeout.
Develops and maintains an active education, training, and PRC awareness program to staff, patients, visitors, and the community.
Supervises PRC Case Managers and is responsible for the direction of PRC case management activities.
Counsel employees as necessary on substandard work and noncompliance with Hospital policies governing conduct and performance.
Provides orientation and training to PRC staff, evaluates work performance, performs program reviews, and conducts annual performance appraisals.
Establish effective communication with the community, patients, providers, healthcare facilities, and fiscal intermediary for the scheduling of visits, payment of services, and education of PRC program guidelines.
Maintain and develop position descriptions, performance requirements, and policies and procedures as necessary.
Keeps employees informed of changes in procedures, regulations, and policies affecting the services.
Responsible for ensuring the program is expended in compliance with regulatory requirements and Hospital guidelines.
Serves as SMH’s technical authority to the Purchased Referred Care program.
Responsible for completing and submitting a variety of budgetary documents and reports requested as part of SMH’s budgetary process.
Responsible for compliance with Prompt Payment Act; ensure all claims are processed on a timely basis.
Represent SMH in external relationships with other PRC organizations, academic institutions, and governmental agencies.
Ensures compliance with standards such as HIPAA, Privacy Act of 1974, Infection Control, and national accrediting bodies (TJS, CMS, OSHA).
Meet and comply with the standards of the Navajo Health Foundation Personnel Manual.
Maintain confidentiality at all times.
Other duties as assigned and contributes to a team effort.