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



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).


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.


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

1. Knowledge of organizational structure for the PRC Program, PRC Policies, Payment process, Eligibility and Alternative Resources.

2. Previous experience in supervising and leading others.

3. 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.

4. Knowledge and understanding of the Affordable Care Act and how it affects those seeking PRC services.

5. Ability to identify and resolve problems as they arise.

6. Ability to effectively communicate verbally and in writing is essential.

7. Must possess leadership qualities and be a person of integrity.

8. 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.

9. Knowledge of Microsoft Office Suite; Microsoft Word; Microsoft Excel; design software; internet software; and electronic database health records systems.

10. Prior experience working with PRC or contract health services (CHS) with IHS, a Tribe, or Tribal Organization


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.