Yoeme Managed Care Utilization Manager

About the role

The Yoeme Managed Care Utilization Manager (YMCU) works with the Executive Director of Health to plan, organize, direct, coordinate, and lead personnel and work processes of a multi-million dollar program serving the Tribal membership residing in Pima and Maricopa counties. The YMCU Manager assists in managing the Commercial Health Self-Insurance Plan -Yoeme Woi Health Plan, commercial eligibility, and producing Family Status Reports for Woi members.

Responsibilities

• Provide research, analysis, and recommendations to Health Department Executives on service improvement procedures, organizational improvements, and cost control measures.
• Affiliate with managing the Commercial Health Self-Insurance Plan – Yoeme Woi Health Plan, in commercial eligibility and producing Family Status Reports for Woi members.
• Coordinate and communicate across health care service systems, including Inpatient / Outpatient, Specialty services, Pharmacy, CHEF, and special health projects/initiatives.
• Serve as the Tribal Administrator for the Health-e-Arizona (HEA) site.
• Assist in Hospital / Clinical Coordination and Discharge planning with Nursing and Clinic Coordinators.
• Affiliate in Prior Authorization review with the Specialty Clinic Coordinator outside of YHP members.
• Develop and maintain sound administrative policies and management protocols including budgets, cost determination, fee setting and collection structure, and financial reports.
• Perform under minimal supervision with accountability for specific goals/objectives.
• Work with the Executive Director, Deputy Director, Medical Director, and others to develop performance improvement targets for the organization's quality, service, and efficiency.
• Provide leadership with recommendations for implementing changes targeted at contract policy improvement. Measure and evaluate attainment of results.
• Supervise staff to include prioritizing and assigning work, conducting performance evaluations, ensuring staff are trained and employees follow policies and procedures, maintaining a healthy and safe working environment, and making hiring, termination, and disciplinary recommendations.
• Ensure adequate staffing to meet production and quality standards of the program.
• Maintain ambulatory data, inquiries from eligibility providers, intermediaries, tribal members, and complex issues.
• Manage workload distributions for Utilization Review Specialists (URS) and contractor letters.
• Review and issue formal response letters to contractors about program member additions, deletions, and changes, send out notifications of member disenrollment, and review the FI pend report.
• Assign Health Record Numbers (HRN) to newborns/new program enrollees, sign denial letters for YHP and send Urgent Care letters to members.
• Post payments for "I" type purchase orders payable by the Yoeme Health Plan Finance Office and payments for EOBRS that did not process through FI download.
• Generate ad hoc reports from RPMS and CHSMIS as required, generate an open document list sent to providers, and access RPMS and RIC modules.
• Process and coordinate medical referrals for the Phoenix Indian Medical Center (PIMC) and the Pima County El Rio Health Center, provide healthcare for tribal members in Maricopa and Pima County by scheduling appointments, generating purchase orders, and explaining procedures.
• Review medical referrals and claims with assigned committee members; determine medical need, the priority of the request, eligibility, and payer and provide authorization of payment.
• Act as an advocate for patients; performs liaison and case management activities between patients and healthcare providers; provides patient education about eligibility, diagnosis, and insurance.
• Work closely with the Native American Liaison for AHCCCS ensuring equal treatment for our tribal members.
• Monitor contractors to ensure they follow the contract in providing health services to tribal members.
• Participate in discharge planning for patients to ensure appropriate services are in place and that the client is being discharged to an appropriate level of care.
• Perform other duties of a similar nature or level as requested by the supervisor or director.

Qualifications

• Must possess and maintain a valid Arizona Driver's License.
• This position will require the incumbent to work non-traditional hours, nights, and weekends.
• Must have a current Level 1 Arizona Clearance Card or be able to obtain the Level 1 Arizona Clearance Card within ninety (90) days of hire.
• Failure to maintain a current Level 1 Clearance Card will result in removal from this position.

Benefits

The Pascua Yaqui Tribe provides 22 days of Paid Time Off which increases with years of service and 15 paid Holidays per year. We offer a comprehensive healthcare benefit package that surpasses or rivals the biggest organizations in Tucson. We encourage you to stay healthy by providing an onsite Wellness Center. Additionally, the Tribe offers a 401(k) Plan with a generous match in which you're immediately vested along with a profit sharing plan after one year of employment. Sworn police and and fire employees are eligible to make Pre-Tax and After-Tax contributions to the Arizona Public Safety Personnel Retirement Systems ("PSPRS").