Purchased Referred Care Manager

About the role

This position will provide management of the Purchased Referred Care (PRC) program/department to ensure strategic goals and objectives are met. Provide clinical guidance and train non-clinical staff with PRC workflow in coordination with clinical nurses, physicians and financial staff to ensure successful purchase referred care operations. Establish community and payer relationships, whilst adhering to compliance, maintaining payment and financial analysis to ensure effective department functions.

Responsibilities

• Manage all aspects and functions of the PRC program/department.
• Establish and implement guidelines and procedures for effective and efficient processing for authorization and payment of referrals for healthcare services provided to the Western Navajo service area.
• Provide clinical oversight and care coordination to ensure compliance with regulations regarding PRC eligibility requirements, denials, and appeal processes.
• Provide clinical oversight of claim administration and work with case management, clinical nurses, physicians, and PRC team.
• Responsible for staff’s daily entry of referrals/notifications into the claims management system, establishing patient records and processing claims timely and in medical priority.
• Administer PRC program and service in accordance with TCRHCC and Federal laws, regulations, policies, procedures, and guidelines.
• Develop and implement policies and procedures (with clinical components, as needed) regarding eligibility, alternate resource programs, referral/notification process, interdepartmental relationship/workflow and responsibilities.
• Develop an annual PRC spending plan and budget to maximize the funds allocated each fiscal year.
• Resolve informal and formal complaints and grievances within jurisdiction politely with the highest level of customer service (refers appropriately to higher level of management if needed).
• Develop and implement performance improvement plans in coordination with interdisciplinary groups of TCRHCC as needed to achieve departmental objectives.
• Provide training to staff and monitors systems for data entry of all PRC referrals.
• Provide training on proper billing procedures, interpretation of guidelines, verification of claims, and irregularities in billing information received.
• Represent TCRHCC at interagency meetings that may impact PRC policy or result in memorandums of agreement and meetings to support program initiatives.
• Work as a liaison between the PRC department and TCRHCC staff to include outside providers.
• Attend TCRHCC Managed Care Committee meetings and other TCRHCC Committee meetings assigned.
• Initiate and provide oversight of all contracted services for the PRC program.
• Ensure payments are disbursed timely and appropriately.
• Responsible for review, research, and decision of first level appeal process.
• Career Development and Training.
• Coordinate payments to outside providers and contracted services with the Finance and Fiscal Intermediary (FI) team.
• Design financial processes to meet PRC objectives and smooth transitions between NAO, FI, and TCRHCC.
• Career Development and Training.
• Coordinate with multidisciplinary teams to assure policies and procedures regarding patient registration, PRC/PCM/RCIS system, alternate resources, and training methodologies in place are consistent in maximizing the current systems to the systems highest ability to advocate for patient care and PRC funding.
• Evaluate and analyze program structure to determine strategies to improve effectiveness and efficiency.
• Provide advice and recommendation to managers and professional health care providers on costs and benefits of proposed PRC actions.
• Provide oversight of federal appropriation of funds for PRC.
• Works collaboratively with the CQO, Director of Care Coordination and/or Chief Medical Officer in making decisions and recommendations concerning the technical treatment of budgetary data under conditions of high uncertainty and time deadlines.
• Maintain Catastrophic Health Emergency Funds (CHEF) cases.
• Assures requests are appropriate, accurate, and are supported with documentation and in compliance with established PRC guidelines.
• Develops and interprets ad hoc reports (statistical, financial, trends) for decision support, analyses, planning, and evaluation.
• Ensure staff reconciles PRC funds to report to Leadership group the status of funds for PRC on a monthly basis.
• Participate in statistical tabulation of hospital workload from the FI/PCM/RCIS to demonstrate utilization patterns by type of service, provider, diagnosis, community or origin or other relevant parameters and develops plans of action as needed.
• Develop processes and policies and procedures that promote patient access to the appropriate level of care, prevent over or under utilization of resources, maximize the use of alternate resources, and supports continuity of care.
• Aid in ensuring case management services are provided for referred patients identified as needing coordination of services and collaboration from pre admission to post discharge in order to prevent problems caused by lost to follow up.
• Provide decision making tools and analyses for TCRHCC to establish routine reporting, variance analyses, profitability analyses, and sensitivity analyses to help drive insightful decision-making.
• Manage budget and develop forecasts for revenue, operational expenses and capital items.
• Conduct thorough research and analysis of variances to ensure data accuracy.
• Develop and negotiate contracts to ensure all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
• Develop a comprehensive customer service platform that patients can utilize.
• Support in managing contract