Purchased Referral Care Manager Closes 2/27/2025

SUMMARY:

This position is organizationally located in the Purchased Referred Care (PRC) Section of the Fiscal Division of United Indian Health Services (UIHS). This position shall be responsible for managing all administrative functions related to Purchased Referred Care eligibility, referrals to third-party providers in accordance with the rules and regulations under which the organization operates, and assistance to clients in navigating specialty care referrals.   A key responsibility of the position shall be the resolution of enrollment, service delivery and related quality expectation issues through customer focused patient advocacy, including direct communications with clients and clinic providers, acting quickly to determine root causes of issues, and expediting acceptable corrections, adjustments and follow up to ensure resolution.   Under supervision of the Chief Financial Officer the Manager will direct the day-to-day operations of the Purchased Referred Care staff.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

Level I

• Direct the day-to-day management, scheduling, communications, and operations of the Purchased Referred Care staff at all clinic sites.
• Ensure the effective application of the Purchased Referred Care processes. 
• Maintain and improve the levels of positive client experience through informal and formal client interviews, surveys, and market research.
• Act as the primary ombudsman regarding patient advocacy and the day-to-day frontline for non-clinical complaint resolution. 
• Utilize the feedback received from clients, providers, and other clinic staff to continually improve the client experience, including training and performance counseling of supervised staff.
• Prepare and distribute services-related informational materials for the educational benefit of existing and new clients including the specifics of access to available benefits, and explanations of applicable federal, state, third-party payer, and organizational rules and policies. 
• Make suggestions and recommendations to other clinic departments with the objective of improving the access and effectiveness of services to clients, including registration and records documentation, clinic appointment scheduling, minimizing waiting times, referrals to third party clinical specialists, and billing and accounting.

• Maintain a high level of knowledge regarding the operative US Department of Health and Human Services, Indian Health Service, and other Federal and State regulatory bodies regarding administrative and accounting requirements that affect the organization’s operations.
• Familiar with CHEF cases, discusses with Chief Financial Officer for presentation to Chief Executive Officer and the Board of Directors.
• Represent the department at internal committee meetings, work groups, including Board of Directors meetings.
• Attend and recommend external seminars and trainings to assist in maintaining the department’s competency. 
• Develop policies, procedures, and protocols in conjunction with clinic services for Purchased Referred Care.
• Actively participate in improvement activities, including but not limited to accreditation, meaningful use, and patient centered medical home initiatives. 
• Assist Chief Financial Officer with internal and external reports and studies in accordance with defined guidelines and regulatory requirements.
• Support the adherence to the organization’s accreditation and compliance standards and guidelines.
• Prepare and present the quarterly and annual report to the Board of Directors under the direction of the Chief Financial Officer.
• Suggest medical procedures for inclusion in Purchased Referred Care Medical Priorities Table.
• Extensive knowledge of RPMS, including an awareness of meeting the financial needs of paying referrals.
• Other duties as assigned.

Level II – Demonstrates competency in all activities identified in Level I duties.

• Independently prepares and presents the quarterly and annual report to the Board of Directors.
• Familiarity with Level 1-Level IV Medical and Dental Priorities.
• Capable of providing the Board of Directors with suggestions and input into development of additional priorities.
• Fluid in documentation.
• Manages Purchased Referred Care register in RPMS.
• Demonstrates a skill set capable or representing the department independently at various venues such as Board of Directors meetings, work study group meetings affiliated with the Indian Health Service and California Rural Indian Health Board, and tribal and community events.

SUPERVISORY RESPONSIBILITIES:  

• Supervises Specialist and Technicians. 
• Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws.
• Negotiates contracts for PRC patients with outside vendors.
• Demonstrated efficiency in department management.
• Limited supervision by section head of PRC management.
• Capable of representing UIHS at outside venues.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION/EXPERIENCE: Educational degrees must be from a US Department of Education accredited school

• Bachelor’s degree (BA) from a four-year college or university in the field of healthcare administration, marketing, communications, business management or related field; or 
• Eight to ten years related customer services/insurance enrollment experience and/or training; or equivalent combination of education and experience.
• Demonstrated knowledge of federal, state, and private insurance program payment procedures.
• Knowledge of Indian Self-Determination rules and regulations preferred.
• Supervisory and management skill set required.
• Ability to use informed judgment regarding necessary interpretations or adaptations of rules, regulations, and policies.

• Experience in a health care setting preferred.

COMPUTER OPERATIONS
 

• Advanced personal computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc. 
• Ability to successfully navigate and utilize the electronic health record system(s).