Indian Preference in hiring is given to qualified enrolled members of Ketchikan Indian Community (KIC) and Native Americans consistent with P.L. 93-638 and in accordance with KIC policy and other applicable federal laws.
Job Summary
The Purchased and Referred Care (PRC) Director is responsible for the management and oversight of the PRC department, ensuring efficient and effective utilization of resources to provide (through referral and PRC funding) comprehensive healthcare services to eligible American Indian and Alaska Native patients. This role includes planning, directing, and coordinating medical referral services, financial operations, and compliance with KIC Tribal Health Clinic and Indian Health Services (IHS) policies and federal regulations
The director will provide leadership and guidance for establishing production and work flow systems, setting production and quality standards, defining all operating policies and procedures and claims processing guidelines, coordinating with other departments to ensure that claims payment functionality is optimized to achieve business, operations and reporting objectives, and assuring that goals are met. The director will also participate in Accreditation Association for Ambulatory Health Care (AAAHC) activities and have a complete understanding of CFR42, IHS and PRC regulation and KIC THC PRC policies and procedures.
Job Duties & Responsibilities
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Maintains a culturally responsive PRC department through staff training and adhering to policy and procedures while ensuring providers and patients are assisted in getting the care they need, even when it is not covered in the PRC budget.
- Coordinate patient/client referrals necessary to fulfill PRC requirements and guidelines.
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Ensure patient/client access and signing up to health insurance programs.
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Facilitate negotiations and payments on behalf of PRC eligible patients and clients.
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Provide accurate records for expenditures relevant to the health program especially the PRC program.
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Some travel required for training sessions and conferences.
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Monitor PRC operation budget and submit written requests for supplemental PRC funds or justifiable changes if necessary.
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Oversee the authorization and processing of medical referrals to external providers.
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Monitor and evaluate program effectiveness and make improvements as needed.
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Manage the PRC budget, ensuring cost-effective use of funds ensuring KIC is the payer of last resort.
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Facilitates PRC Committee to develop, monitor, and enforce financial policies and procedures for PRC and annual operational budget to maximize the PRC funding.
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Distribute monthly funds status reports of current PRC funding levels to KIC THC Leadership through the Health Administrator.
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Oversee payment processes for services provided by external healthcare entities.
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Develop and implement quality assurance programs to monitor service quality and patient outcomes.
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Conduct audits and reviews to ensure program integrity and compliance.
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Collaborate with healthcare providers, hospitals, and other agencies to coordinate patient care.
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Ensure timely access to necessary medical services for patients referred outside of IHS facilities.
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Address issues related to service delivery, patient satisfaction, and quality of care.
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Provides for PRC onboarding and annual training to providers and support staff.
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Current on alternate resources, cost of care locally versus travel
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Responsible for reporting potential cases for the Catastrophic Health Emergency Fund (CHEF); work closely with PRC staff to monitor the high-cost cases funded through the CHEF program as established by P.L 100-713 Section 202 and ensures timely close out of all CHEF cases.
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Maintain partnership, MOA’s, Agreements, and/or contracts with third-party payor(s) and clearinghouse (s). Monitoring the use of diagnostics tests and referrals for compliance with area and local criteria standards.
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Responsible for establishing and maintaining KIC THC PRC department and administrative policies.
- Oversees the program planning, development, administration, management, operation, and evaluation of the KIC THC PRC Program.
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Ensure current eligibility criteria is followed which requires familiarity with the regulations and ability to explain to providers and PRC program staff. Work with the KIC attorney when appropriate. Prepare necessary correspondence to providers and patients concerning patient PRC eligibility.
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Conduct community outreach and education. Ensure patients, private providers, and other agencies understand PRC is the last payor for medical services and funding is available upon meeting eligibility criteria.
- Maintain appeal records files in keeping with the appeal process contained in Federal regulations or policies.
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Develops and proposes effective department guidelines in keeping with approved Tribal Council Policies and Ordinances.
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Performs other duties as assigned.
Necessary Knowledge, Skills, and Abilities
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In-depth knowledge/experience in claims processing in a health care setting.
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Current knowledge of Medicare-like rate.
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Ability to build effective relationships with providers of services.
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Superior interpersonal, communication, problem solving and decision-making skills.
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Flexibility, initiative, and ability to work as a team player.
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Organizational skills to effectively establish work priorities in accordance with objectives and standards.
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Familiarity with applicable computer software and databases.
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Strong understanding of the IHS PRC program, including policies, procedures, and federal regulations.
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Knowledge of healthcare financing, billing, and reimbursement processes.
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Excellent organizational and leadership skills.
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Strong analytical and problem-solving abilities.
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Effective communication and interpersonal skills.
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Basic medical knowledge for handling the PRC cases including medical billing and terminology.
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Knowledge of Electronic Health Records (EHR) and other relevant clinical and administrative resource tracking programs.
KIC Competencies
Cultural Competency: To be respectful and responsive to the health beliefs, practices, and cultural and linguistic needs of KIC Tribal Members. Developing cultural competence is an evolving, dynamic process that takes time and occurs along a continuum.
Commitment: To serve Tribal Members and set a high standard for yourself in your performance; strive for results and success; convey a sense of urgency and bring issues to closure; and stay persistent despite obstacles and opposition.
Customer Service: Meet/exceed the expectations and requirements of internal and external customers; identify, understand, and monitor the needs of both internal and external customers; always talk and act with customers in mind; and recognize working colleagues as customers.
Effective Communication: Ensure important information is passed to those who need to know; convey necessary information with respect, clearly and effectively orally or in writing
Responsiveness and Accountability: Demonstrate a high level of conscientiousness; hold oneself personally responsible for one's own work; and do the required fair share of work.
Working Conditions
The physical demands described here are representative of those that an employee must meet to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.
While performing the duties of this Job, the employee is regularly required to use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is frequently required to stand and/or sit. The employee is occasionally required to walk, sit, climb, or balance. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, peripheral vision, and depth perception. The noise level in the work environment is usually average.
Conditions of Hire
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May be required to possess and maintain a valid driver's license or capable of obtaining one, as well as be insurable by KIC’s company insurance.
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KIC is a Drug-Free Workplace. All employees must adhere to KIC drug and alcohol policies and procedures to ensure a safe workplace. Employees must pass a pre-employment and subsequent random and/or for cause drug and alcohol screening to be eligible for and maintain employment.
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KIC has several positions that must comply with the P.L. 101-630 Indian Child Protection and Family Violence Protection Act (ICPA); all employment offers in the "covered" classification are conditional until KIC has received a Federal criminal background check verifying eligibility to work in these programs.
This Job Description describes the essential duties and qualifications. It is not an exhaustive statement of all the job duties, responsibilities, or qualifications; management has the exclusive right to alter or add to this job description at any time without notice. Incumbent(s) may not be required to perform all duties listed and may be required to perform additional duties as assigned.
Minimum Education & Experience Required
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Bachelor’s Degree in health-related or business field.
- Three years progressive administrative management experience in third party administration or related field.
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A combination of relevant experience, education, and training may substitute for education and experience requirements on a year-for-year basis.
Preferred Education & Experience
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Experience in case management.
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Experience in community clinic preferred and a strong commitment to multi-disciplinary teamwork.
