Ensures beneficiaries of CIHA receive the appropriate care at the appropriate time at least possible cost to CIHA. Provides overall direction of the day-to-day operation of the Purchased and Referred Care service department of the Cherokee Indian Hospital Authority (CIHA). Includes the areas of case management, resource management, scheduling, follow-up with patients, follow-up with outside-providers, follow-up with internal providers, coordination of medical information with medical records, and coordination of third-party benefits and accounts payable for patient claims. Ensures that the areas of responsibility are in accordance with the established guidelines and procedures of the CIHA, federal law, state law, and tribal law.
Complexity of Duties
Requirements are complex in that they require comprehensive skills in Case Management and Utilization Review and the sufficient knowledge of medicine to evaluate patient care. This may involve difficult interactions with the clinical staff, case managers, and insurance payers and require maximum skills in diplomacy and judgment. Comprehensive financial management and reporting skills are required.
Works under the general guidance of the Executive Director of Budget and Finance and works within established guidelines for Purchased and Referred Care services. Has wide latitude for independent thinking in the attainment of goals and objectives. Function with little or no supervision.
Responsibility for Accuracy
Deals with exact and precise figures/data. Most errors would be detected within the accounting systems and proofing procedures. This position provides financial data to the CIHA on which operational or financial decisions are based. Undetected errors could range from minor to significant in effect. Responsible for accuracy of work performed by subordinates.
Contacts with Others
Contacts are with patients of all ages, families, hospital personnel, community agencies, and insurance carriers. Contacts with patients, families, and hospital personnel are to exchange, provide, and obtain information concerning the patient’s physical and psychosocial health care problems and needs. Contacts with other health care or related disciplines and insurance carriers are for the purpose of coordination, collaboration, and consultation in meeting the patient’s health care needs. Tact, decorum, and professional etiquette are required in the exchange of information.
The incumbent has access to highly confidential patient medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and all other pertinent information that comes to his/her attention or knowledge. The Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action.
Close concentration and attention to detail are required for sustained periods. Subject to frequent interruptions requiring varied responses. Job duties routinely require visual acuity, manual dexterity, and the ability to speak, hear, walk, sit, stand, bend, and reach with arms and hands. May occasionally move more than 15 pounds.
Works in a normal business office setting with occasional visits outside locations. Work is conducted within a hospital setting and immunizations are required.
Extent of Supervision
Has responsibility for the financial management for the CIHA Purchased and Referred Care program including budget and personnel. Assists in the maintenance of an effective organization through selection, motivation, training, evaluation, and discipline of employees.
Scope of Supervision
Supervises five (7) employees in the department.
Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.