Purchased Referred Care Manager

POSITION SUMMARY

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. This position will have clinical oversight responsibilities and is key to the success of this position is an emphasis on communication, workload allocation, process improvement, training, and delegation.

Education:
Bachelors’ degree in Nursing

License/Certifications:
• A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States, The Commonwealth of Puerto Rico, or a territory of the United States
• Must have and maintain current valid certification of the following throughout employment:
o Basic Life Support (BLS) Certification from the American Heart Association
o National Incident Management System (NIMS) must be completed within 6 months of hire

Experience:
• At least two years of acute care nursing experience
• Must have three (3) years of progressive management responsibilities such as a Charge Nurse, Lead Nurse and/or Nurse Manager
• One year of supervisory experience

Other Skills and Abilities:

A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers.  All employment references must address and indicate success in each one of the following areas:

• Positive working relationships with others
• Possession of high ethical standards and no history of complaints
• Reliable and dependable; reports to work as scheduled without excessive absences
• Ability to multi-task, prioritize and manage time to strict deadlines
• Must demonstrate Customer Service/Conflict Resolution Experience.
• Demonstrate ability to prioritize, communicate effectively, and problem solve
• Organization and management of a flexible schedule to meet the changing demands of the job
• Skilled with budget development and budget management
• Proficient with the Microsoft Suite applications – Word, Excel, Outlook, Power Point, Access
• Strong interpersonal skills; excellent verbal and written communication skills
• Solid analytical, creative and problem-solving abilities; ability to assist, direct and coordinate others
• Ability to work in an organized, efficient manner with a high-level of accuracy, attention to detail and timely follow-through
• Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
• Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading, or incomplete information, as determined by TCRHCC.

PROBLEM SOLVING

Incumbent works with relative independence in program management to improve processes and application of services to patients, providers, other managers, and other outside agencies; confers with the CFO and/or Senior Leaders regarding problems of unusual difficulty.

MENTAL AND PHYSICAL EFFORT

The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical:

This position requires an individual of high energy who can maintain a long and flexible schedule to meet the management requirements. The physical requirements include sitting at a desk for long periods of time, long periods of sitting in meetings; frequent sitting for intense work on a personal computer, frequent walking to interact with staff within the facility, frequent bending, kneeling, crouching, twisting, maintaining balance and reaching. Must be able to hear, speak and comprehend over the telephone and in person with others. Must have ability to lift, push and pull up to 50lbs frequently. Sensory requirements for position include prolonged ability for far, near, and color vision, depth perception, seeing fine details, hearing normal speech, telephone use and ability to frequently hear overhead pages. Must have ability of both hand manipulation in simple and firm grasping, fine manipulation, and use of keyboard.

Mental:

Uses independent judgment and analytical skills to make decisions that impact operations, finances, and customer service within the organization. The incumbent must have the ability to perform in structured and unstructured environments and possess a keen attention to detail and propose practices/mechanisms to enhance customer satisfaction. Must have ability to continually concentrate, handle a high degree of flexibility, handle multiple priorities in stressful situation, demonstrate high degree of patience, adapt to shift work, work in areas that are close in crowded, frequently cope with high levels of stress, make decisions under high pressure, work alone, and occasionally cope with anger/fear/hostility of others in a calm way and manage altercations.

Environmental:

May frequently be exposed to chemical agents, extremes in temperature of humidity, occasional exposure to infectious diseases, dust, fumes, gases, hazardous or moving equipment, and loud noises.

ESSENTIAL FUNCTIONS

1. 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.
2. Provide clinical oversight and care coordination to ensure compliance with regulations regarding PRC eligibility requirements, denials, and appeal processes.
3. Provide clinical oversight of claim administration and work with case management, clinical nurses, physicians, and PRC team.
4. 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.
5. Administer PRC program and service in accordance with TCRHCC and Federal laws, regulations, policies, procedures, and guidelines.
6. 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.
7. 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).
8. Develop and implement performance improvement plans in coordination with interdisciplinary groups of TCRHCC as needed to achieve departmental objectives.
9. 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. 
10. 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
11. 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. 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.
12. 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.
13. 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. Monitors, identifies, and manages the Catastrophic Health Emergency Funds (CHEF) cases. Assures requests are appropriate, accurate, and are supported with documentation and in compliance with established PRC guidelines.
14. 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.
15. 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.
16. 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.
17. Assist 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.
18. 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.
19. Manage budget and develop forecasts for revenue, operational expenses and capital items.
20. Conduct thorough research and analysis of variances to ensure data accuracy.
21. Provide support in managing contract negotiation, ensuring all terms and conditions of contracts are met and that TCRHCC obtains the most advantageous offer.
22. Develop a comprehensive customer service platform that patients can get timely support from.
23. Participate in various finance improvement projects and actively contribute to realizing process improvements.
24. Other duties as assigned.