Director of Purchased Referred Care

Tohono O'odham Nation Healthcare

2d•Onsite

About The Position

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center. Position Summary: This position provides leadership in managing, coordinating, facilitating, and assessing the Purchased 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 Purchased Referred Care (PRC) within the Tohono O'odham Nation Sells Hospital in Sells, Arizona. The incumbent will serve as the Division Director of Purchased/Referred Care. Incumbent reports to the Chief Executive Officer.

Requirements

Knowledge of the Tohono O'odham culture, customs, and traditions.
Knowledge of the theories, principles, practices, and techniques of program planning and evaluation.
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.
ThoroughknowledgeofPublicLaw94-437,TitleIVoftheIndianHealthCare ImprovementAct, and Public Law 99-272, the Federal Medical Care Cost Recovery Act.
Knowledgeoffederalpolicyandregulationofalternateresources,CFR42-36.21(A)and 23(F).
Thorough knowledge of Purchased Referred Care and the managed care model of healthcare delivery includes utilization review, pre-admission authorization, concurrent review criteria, discharge planning, and medical terminology.
Comprehensiveknowledge of alternative resources, such as Medicare, Medicaid, and private insurance, and PRC program eligibility requirements, including knowledge of reimbursable insurance procedures and requirements, including the ability to interpret provisions of individual health plans and group plans.
Knowledgeand 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.
Abilitytodevelopandmaintaineffectiveworkingrelationshipswithhealthcare personnelofmanydisciplines, administrators, and officials of tribal, federal, state, local, professionals, private, public, andvoluntaryagenciesand
Possessstronganalytical,writing, and verbal communication skills to effectively interact with State agencies, Indian Health Service, Tribal and urban programs, and anarrayofstaffandindividualsfromtheprivate
Thoroughknowledgeofbudgetandfiscalmanagementconceptsto combine and consolidate financial data into useful decision-making
ThoroughknowledgeofthePrivacyActof1974.
KnowledgeofHealthInsurancePortabilityandAccountabilityActof1996,PublicLaw 104-191(HIPAA).
Mustbefamiliarwithpreparingbidsandcontractdocuments(includingcost estimatesandspecifications).
Experiencewithrecentversionsofwordprocessingand spreadsheetsoftware(e.g., MSWord/Excel/PowerPoint)togeneratenecessary documentsandperforms
Ability to travel within the interior/exterior boundaries of the Tohono O'odham Nation.
Bachelors Degree in nursing preferred or closely related field.
Nurse Applicants must have an active, current, and unrestricted license as a professional nurse in a State of the United States.
Two years of PRC work experience, case management, or utilization review experience.
Two years of supervisory experience.
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.

Nice To Haves

A Bachelor's Degree in Hospitality Management is preferred.

Responsibilities

Manage the overall Purchased 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 are followed in 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 the reporting of 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 Purchased 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 a variety of budgetary documents and reports required as part of TONHC's budgetary process.
Responsible for compliance with Prompt Payment Act; ensures all claims are processed on a timely basis.
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.