Purchased Referred Care Manager

Program:	Fallon Tribal Health Center		Salary Grade:	GS – 13
Supervisor:	Associate Director of Business Services		Salary Range:	$20.56-$24.55
FLSA Status:	X Exempt      Non-Exempt     Public Safety		Position Type:	Full Time

POSITION DESCRIPTION

The Purchased/Referred Care Manager serves as the supervisor for the PRC Office which provides support, ensures regulatory compliance, and technical assistance involving patient referrals for medical and other health care services to eligible beneficiaries not available at the Health Center and for maintaining the effectiveness and efficiency of the PRC Program based on funds allocated for the program from the Indian Health Service (IHS).

ESSENTIAL DUTIES & RESPONSIBILITIES

1. Develops, coordinates and integrates the operations of the PRC program in accordance with approved policies and directives pertinent to the administration and management of the PRC program.
2. Plans and provides program goals and operation guidelines; defines and communicates objectives and priorities; interprets approved policies/procedures and federal regulations.
3. Makes decisions involving individual patient situations by utilizing general guidelines and precedents to new and changed situations that may affect a patient’s eligibility as it pertains to the PRC policy.
4. Provides interpretation of guidelines, verification of claims, appropriateness of services and irregularities in billing information received.
5. Ensures that Medicare-like Rates (MLR) are applied to applicable claims.
6. Ensures proper processing of patient eligibility and referrals.
7. Oversees processing of PRC obligations and coordinates with patients.
8. Submit financial processing of PRC obligations and projected incurred claims to authorized officials.
9. Coordinates referrals and PRC contracts with FTHC providers.
10. Monitors and approves PRC contracts with external facilities and providers, indicating pricing and contract compliance.
11. Establishes a process for ensuring patients register for alternative resources, when it’s identified, to ensure PRC is the payor of last resort.
12. Prepares necessary correspondence throughout the year to explain eligibility guidelines and payment methodology to providers and patients.
13. Maintains record of denials and appeals, along with relevant back‐up documentation.
14. Maintains updates, education and training options to ensure the PRC department is up‐to‐date on the latest changes that affect the program.
15. Prepares referrals for patient services and sends to patient and contract provider and coordinates receipt of approved payor Purchase Orders and reports for payment.
16. Other job-related duties as assigned by the supervisor.

QUALIFICATION REQUIREMENTS

1. Associate degree in business administration or related field (bachelor’s Degree preferred) or equivalent amount of PRC experience.
2. Minimum of four (4) years of related experience.
3. Two (2) years supervisory or management experience preferred.

KNOWLEDGE, SKILLS & ABILITIES

(To perform this job, an individual must be able to perform each essential duty satisfactorily. Requirements, below, are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to individuals with disabilities to perform essential functions)

• Knowledge of organizational structure for the PRC Program, PRC Policies, Payment process, Eligibility and Alternative Resources.
• Previous experience in supervising and leading others.
• Knowledge of current health care issues and emerging trends of the public and private health care industry, including an understanding of payor contracts and pricing.
• Knowledge & understanding of the Affordable Care Act & how it affects those seeking PRC services.
• Ability to identify and resolve problems as they arise.
• Ability to effectively communicate verbally and in writing is essential.
• Must possess leadership qualities and be a person of integrity.
• Must be able to deal effectively with people and relate well in dealing with people; have the ability to establish and maintain effective working relations with other employees, officials and the public.
• Knowledge of Microsoft Office Suite; Microsoft Word; Microsoft Excel; design software; internet software; and electronic database health records systems.
• Prior experience working with PRC or contract health services (CHS) with IHS, a Tribe, or Tribal Organization

OTHER REQUIREMENTS

1. The duties of this position include mandatory reporting pursuant to 1) the Victims of Child Abuse law (34 USC § 20341) and 2) elder and vulnerable person laws (NRS 200.5093), as incorporated by decision of the FBC that elders and those who cannot speak for themselves are entitled to the same protections. Because such laws may subject employees to criminal penalties under FPST LOC § 5-50-040 and/or 18 U.S.C. §§ 1169 and 2258, all employees hired to this position must complete a Mandatory Reporter training within 90 days of hire.

EMPLOYMENT INFORMATION

Fallon Paiute-Shoshone Tribe and Native American/Indian Preference:  Employment preferences to members of the Fallon Paiute-Shoshone and to members of federally-recognized Indian Tribes shall apply to this position pursuant to the Tribe’s Personnel Policies.  Persons of Tribe and/or Indian ancestry and wish to claim these employment preferences should submit a copy of the Tribal Enrollment Card/Certification indicating the name of the Tribe they are enrolled with.

U.S. Veteran’s Preference:  Preference to opportunities to veterans honorably discharged from the United States Armed Forces shall apply to this position pursuant to the Tribe’s Personnel Policies.

Equal Opportunity Employer:  The Fallon Paiute-Shoshone Tribe does not discriminate on the basis of race, color, national original, sex, religious preference, age, handicap, marital status, political preference, genetics or membership or non-membership in any employee organization, except as allowed by Federal and/or Tribal Law.

Drug Free Workplace:  The Fallon Paiute-Shoshone Tribe is a drug-free workplace.  All employees are subject to a pre-employment and random drug screens.

Driving Record:  Employees who drive tribal vehicles must have a valid Nevada Driver’s License, be insurable under the Tribe’s vehicle insurance program, and must also provide a DMV printout annually.

Background Checks:  All employees must be able to pass a background check per the Tribe’s Background Check Policy.

Position Description Limitations:  This position description does not constitute an employment agreement between the Tribe and the employee, and is subject to change by the Council as the needs of the Tribe and the requirements of the job change.  This position description is not intended to present a descriptive list of the range of duties performed by any employee in this position and is not intended to reflect all duties performed within the position.