Director of Purchased Referred Care

Job Description

Job Description

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, Casa Grande, and San Xavier Health Center

Position Summary:

This position provides leadership in managing, coordinating, facilitating, and assessing the Purchase Referred Care Division of Tohono O'odham Nation Health Care. The incumbent provides operational direction and oversight, including coordination and distribution of workload.

Scope of Work:
This position is located in the Division of Purchase Referred Care (PRC) within the Tohono O'odham Nation Sells Hospital in Sells, Arizona. The incumbent will serve as the Division Director of Puchase/Referred Care. Incumbent reports to the Chief Executive Officer.

Essential Duties and Responsibilities: (Depending on the area of assignment, an incumbent may not be required to perform some of the duties listed below):

• Manage the overall Purchase Referred Care program (formerly known as Contract Health Services, CHS). Maintain the effectiveness and efficiency of the PRC program.
• Develops, coordinates, and integrates operational plans, policies, and procedures.
• Adapt PRC guidelines and precedents to new or changed situations and apply alternative methods, techniques, and approaches.
• Develops an annual PRC spending plan to maximize the funds allocated each fiscal year.
• Develops statistical data from available reports and other sources to develop, review, approve, and recommend changes to TONHC PRC program operations and budgets.
• Weekly fund status reports are maintained to provide the current PRC funding level to the Managed Care Committee.
• Provide interpretation of guidelines, verification of claims, appropriateness of services, and irregular billing information received to TONHC CEO and PRC staff regarding services with hospitals, clinics, physicians, dentists, and other non-TONHC providers.
• Ensures that current eligibility criteria for the TONHC PRC program follow the administration of the PRC program. Obtains clarification from healthcare attorney when appropriate.
• Maintain appeal records.
• Advises CEO regarding PRC denials and appeals.
• Responsible for reporting 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.
• Responsible for the direction of PRC case management activities. Supervise PRC case managers.
• Counsels employees as necessary on substandard work and non-compliance with Hospital policies governing conduct and performance.
• Provides orientation and training to PRC staff, evaluates work performance, performs program reviews and annual performance appraisals.
• Develops or updates 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 eight million dollar program is expended in compliance with regulatory requirements and Hospital guidelines.
• Serve as the TONHC's technical authority on the Purchase Referred Care (Contract Health Services) program.
• Serves as software program manager of PRC/Management Information Services and Referred Care Information Systems databases.
• Responsible for completing and submitting various budgetary documents and reports required as part of TONHC's budgetary process.
• Responsible for compliance with the Prompt Payment Act; ensures a timely process of all claims.
• Represent TONHC in external relationships with other PRC organizations, academic institutions, and governmental agencies.
• Keeps track of transplant patients ensuring treatment plan is obtained for future continuity of care for the patient.
• Ensures compliance with standards such as HIPAA, Privacy Act of 1974, Infection Control, and national accrediting bodies (TJC, CMS, OSHA)
• Other duties as assigned and contributes to a team effort.

Knowledge, Skills, and Abilities:

• Knowledge of the Tohono O'odham culture, customs, and traditions.
• Knowledge of program planning and evaluation theories, principles, practices, and techniques.
• 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 (CHS) 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 Purchase 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 conditions, 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 Tohono O'odham Nation.
• Ability to develop and maintain effective working relationships with health care personnel of many disciplines, administrators, and officials of tribal, federal, state, local, professionals, private, public, and voluntary agencies and organizations.
• Possess strong analytical, writing, and verbal communication skills to effectively interact with State agencies, Indian Health Service, 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 perform calculations.
• Ability to travel within the interior/exterior boundaries of the Tohono O'odham Nation.

Minimum Qualifications:

• Bachelor's Degree in Business Administration, Health Care Administration, or closely related field; and
• Two years of contract health or purchasing services experience.
• Two years of supervisory experience.

Licenses, Certifications, Special Requirements:

• Upon recommendation for hire, a criminal background and a National FBI fingerprint check are required to determine suitability for employment, including a 39-month driving record.
• May require possessing and maintaining a valid driver's license (no DUIs or major traffic citations within the last three years).
• If required, must meet the Tohono O'odham Nation tribal employer's insurance requirements to receive a driver's permit to operate program vehicles.
• Based on the department's needs, incumbents may be required to demonstrate fluency in both the Tohono O'odham language and English as a condition of employment.
  

Physical Demands:
While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit; walk; use hands to finger, handle, or feel; reach with hands and arms; stoop, kneel, crouch, crawl, climb, or balance. The employee must frequently lift and move up to 50 pounds or more. This job's specific vision abilities include close vision, distance vision, peripheral vision, and the ability to adjust focus. The employee may experience exposure to adverse environmental conditions, such as dirt, dust, odors, wetness, temperature and noise extremes, fumes, hazardous materials, machinery, vibrations, electric currents, traffic hazards, and toxic agents. Some work is required inside the hospital, exposing the employee to contagious diseases. The job may require working weekend rotations.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive