Referral Department Manager

Position Summary:

Under direct supervision of the Business Office Manager, the Referral Department Manager is responsible for the Referrals Department, Fiscal Intermediary operations, maintaining Purchased and Referred Care (PRC) Program standards, Tribal Medicaid Federally Qualified Health Centers (TMFQHC) requirements, fiscal and administrative oversight on access and cost of care initiatives. Maintains confidentiality of all privileged information.

Duties:

· Establish a close working relationship with all specialty care offices, PRC Preferred Providers, TMFQHC Providers, diagnostic imaging centers, etc., ensuring effective compliance with payment agreements; serve as the first level manager in addressing provider group concerns, inquiries or opportunities for establishing and expanding provider relations.

· Ensures departmental compliance with PRC Program in accordance with the Code of Federal Regulations (CFR), specifically42 CFR, Part 36 § 36.23”; ensures departmental compliance with PRC priority levels of care, providing management and PRC Managed Care Committee with time sensitive Obligation and Cost of Care Reports on a weekly, monthly and quarterly basis; makes initial recommendation on expanding or decreasing Priority Levels of Care

· Serves as primary Supervisory contact for all patient and provider inquiries on referral and/or payment status of claim; maintains and reports time sensitive payment reports to Management ensuring effective compliance with Preferred-Provider Payment provisions

· Provides guidance to Referrals Department and Fiscal Intermediary staff; collaborating with all clinical departments to ensure consistency in referral and fiscal adjudication workflow within established guidelines.

· Audits referrals to ensure referral utilizes PPO/HMO network as primary payor, utilizes PRC and/or TMFQHC contract providers; and appropriate preauthorization and final claim documents are obtained; audits claims submitted for payment to ensure accuracy, fee schedule discounts and agreement compliance, and timely filing provisions are met

· Ensures departmental compliance and ongoing improvement of patient and provider communications; ensures accuracy of necessary documentation for referred healthcare services; provides updates on tasking to Health Information Management, billing and clinical staff for appropriate and timely follow-up

· Complete initial reconciliation report of all adjudicated payments including check or EFT payments; finalize reconciliation process with Health Center Accountant for fiscal compliance

· Ensures departmental compliance with TMFQHC designation, ensuring Centers for Medicare & Medicaid Services (CMS) Written Care Coordination Agreements requirements are met; suggest appropriate provider agreements and recommended fee schedule updates to the Business Office Manager

· Provides program oversight and guidance for staff, patients, health providers or professional groups on eligibility requirements and program limitations for subsidized PRC and TMFQHC referrals

· Prepares submission of PRC referral request to PRC Managed Care Committee for funding obligation approval; reports TMFQHC referrals report to Management for appropriate tracking

· Prepares PRC referral approvals, deferrals and denials based on applicable PRC regulations; communicating with patients both verbally and in writing for time sensitive authorization or grievance provisions

· Prepare Catastrophic Health Emergency Fund (CHEF) claims, ensuring all pertinent information is timely submitted; establish CHEF log for potential claim tracking; report and prepare claim documents for all Diagnosis Related Group (DRG) and Third-Party Liability Cases

· Lead Quality Assurance and Referral Utilization Reviews to management and during the PRC Managed Care Committee meetings

· Compiles information for periodic and special reports to Management; maintaining effective filing systems and data entry accuracy

· Performs other duties as required.

Minimum Qualifications:

· High School Diploma or GED; Required

· 5 years’ experience as a Medical Assistant, Medical Office Referrals, Case Management, in a medical office setting; Required

· Must be able to successfully pass a pre-employment drug/alcohol screen and background investigation.

· Preference will be given to qualified Native American Indians.

Knowledge, Abilities, Skills, and Certifications:

· Knowledgeable with Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9) codes. High level of proficiency relating to medical terminology and strong healthcare background.

· Knowledge of various insurance benefits and Purchase and Referred Program requirements.

· Knowledge of modern office practices, procedures, and equipment

· Knowledge of business English, proper spelling, grammar, punctuation, and basic arithmetic

· Ability to effectively communicate orally and in writing in order to gather and exchange information with individuals both inside and outside of the organization.

· Knowledge of records management and basic accounting procedures

· Ability to communicate effectively and work with people from diverse cultures, ethnic and socio-economic backgrounds with knowledge of Indian community and sensitivity to needs

· Ability to establish and maintain professional relationships with professional groups, and health providers at all levels.

· Ability to represent the organization in a professional manner, building respect and confidence.

· Ability to maintain confidentiality.

· Ability to handle multiple tasks and meet deadlines.

· Ability to carry out instructions furnished in verbal or written format.

· Ability to work independently with minimal supervision.

· Ability to demonstrate excellence in everything, and continually seek improvement in results.

· Skill in operating business computers and office machines, including in a Windows environment, specifically Word, Excel, Access, and presentation software (such as PowerPoint).

Physical Demands:

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee frequently is required to walk. The employee occasionally is required to stand; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds.

Work Environment:

Work is generally performed in an office setting with a moderate noise level.

PLEASE NOTE: Hiring preference will be given to qualified tribal members of Reno-Sparks Indian Colony followed by members of other federally recognized tribes. Must pass and comply with the HR Policy 164.905- PL101.630. The Reno-Sparks Indian Colony requires a designated candidate to successfully complete a pre employment drug screen, criminal background check, and confirmation of professional references and certifications.

Job Type: Full-time

Pay: $69,492.00 per year

Education:

• Bachelor's (Required)

Experience:

• Case management: 1 year (Required)

Ability to Commute:

• Reno, NV 89502 (Required)

Ability to Relocate:

• Reno, NV 89502: Relocate before starting work (Required)

Work Location: In person

Salary : $69,492