Cherokee Indian Hospital Authority is an Equal Opportunity Employer (Minorities/Females/Disabled/Veterans).  To read more about this, view the EEO is the Law poster and this EEO is the Law Poster Supplement

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Purchased and Referred Care Manager
Job Code:2022-02-006
Department:Purchase & Referred Care
FT/PT Status:Regular Full Time
Salary Minimum69,219
Salary Midpoint86,523
  
Position Closes:

Job Responsibilities & Qualifications:

Primary Function

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.

 

Job Description

  • Plans, directs, and supervises the day-to-day work of the Purchased and Referred Care staff including care coordination, Scheduling, claim payment, outside provider collaboration.
  • Ensures procedures are in place to receive all necessary information for payment of claims
  • Coordinates patient’s third-party benefits
  • Monitors all processes and workflows to ensure patients receive the appropriate care at the appropriate time with the least cost to CIHA to ensure positive health outcomes for the Eastern Band of Cherokee Indians.
  • Ensures payments are processed timely.
  • Responsible for the development and monitoring of the annual CHS budget.
  • Maintains a dashboard of metrics that inform and support CIHA health initiatives and leadership team decision making.
  • Coordinate with the Tribal managed care entity to ensure the positive health outcomes of the EBCI’s most vulnerable population.
  • Responsible for the development, implementation and compliance with all Cherokee Indian Hospital Authority, Indian Health Service (I.H.S.) Purchased and Referred Care policies procedures and regulations, and Tribal policies.
  • Authorizes purchase orders for the Purchased and Referred Care Services in RPMS following standard policies and procedures for timely payment.
  • Develops, monitors and implements policies and procedures to ensure compliance with 42 CFR Part 136.
  • Monitors   and   maintains   integrity   of   the   Purchased   and   Referred   Care
  • Maintains the Service/Management Information System.
  • Maintains constant communications with the Executive Director to advise of situations and remain informed.
  • Schedules and facilitates the Managed Care Committee in conjunction with the Medical Director
  • Active member of the eligibility committee
  • Responsible for financial coding of authorizations each fiscal year via the proper Can Numbers and Object Class Codes which indicates the type of service provided by medical/surgical specialties. 
  • Monitors PRC sub-ledger for tracking referrals and reporting usage.
  • Assists CIHA staff with Purchased and Referred Care service questions.
  • Assists auditors, governmental agency employees, vendors, and others with questions and information.
  • Assures all funds are obligated as-close-as-possible to Fiscal Year’s end
  • Management of Resource Corporation of America (alternate resource partner) contracts and audits for appropriate billing.
  • Manages the Alternate Resource Sponsorship program.
  • Reviews all referred patients for ACA appropriateness and refers to the ACA Coordinator for sponsorship.
  • Review for Medicare part D (pharmacy), Analenisgi Inpatient, Medical Inpatient sponsorship
  • Monitors referrals for Provider appropriateness and notifies Primary Care Team of inappropriate referrals.
  • Reviews denials as requested by patients, and overturns or supports the denial.
  • Establishes, contracts, monitors and maintains relationships with outside providers
  • In coordination with CIHA medical providers, establishes evidence-based provider metrics and memorializes in provider agreements. 
  • Establishes a provider network and ensures they know: payment terms, medical-note requirements, billing policies, and secondary referral processes.
  • Troubleshoot issues that arise for all areas of PRC
  • Handles patient concerns timely and efficiently
  • Claims reviews with providers
  • Records un-referred call-in’s
  • Maintains all reports, records, files, and logs as required.
  • Performs all duties according to established safety guidelines and CIHA policies to include,  but  not  limited  to,  direct  patient  contact  within  an  office  and/or hospital setting.
  • Performs other duties as requested by executive director.

 

 

Education/Experience

  • A Master’s Degree in Business Administration and 2 years of healthcare management experience is required or a Bachelor’s Degree in Business Administration and 4 years of healthcare management experience.
  • 2 years of experience in health sciences is preferred.
  • Six to twelve months would be required to become proficient in most phases of the job.
  • Must possess a valid driver’s license.

 

Job Knowledge

  • Must have knowledge of health care financial management, provider payer mechanisms, business environment, and insurance/resource management. 
  • Must have performance improvement skills
  • Must have strategic planning skills
  • Must have knowledge of DRG’s, coding, billing practices, expected lengths of stay per DRG’s and identifying deviation to expected LOS.  
  • Must have knowledge and ability to analyze the results of various medical procedures and translate into appropriate plans of care. 
  • Knowledge of the occupational functions of multidisciplinary health care teams. 
  • Knowledge of culture and health profile of the patient population. 
  • Knowledge and ability to teach and counsel patient/family and staff on plans for care and use of health care resources. 
  • Knowledge of available health care programs and community resources. 
  • Knowledge of JCAHO accreditation standards, nursing quality improvements standards, CMS regulations, Medicare, Medicaid, and private insurance. 
  • Must have ability to communicate to and interact with persons, (staff, health care professionals, individuals in the community) with different functions, level of knowledge, and requirements. 
  • Must possess the ability to manage and control a multi-million-dollar budget.
  • Ability to interpret and apply various regulatory statutes as needed.
  • Must have a demonstrated ability to manage individuals with diverse backgrounds and experience levels.
  • Must have the ability and expertise to work with various regulatory agencies. 
  • Must be able to use a wide variety of office equipment including: computer, typewriter, calculator, facsimile, copy machine, postage machine, and other office equipment as required.
  • Requires the ability to organize work and deal effectively with employees, the public and with federal, state, and tribal agencies.
  • Must be able to communicate both verbally and in writing, follow instructions, and work independently.
  •  

 

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.

 

Supervision Received

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.

 

 

Confidential Data

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.

 

Mental/Visual/Physical

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.

 

 

 

Environment

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.

 

Customer Service

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.