Under general supervision of the Purchased Referred Care (PRC) Manager, provides utilization review and case management for patients referred for inpatient and outpatient care to other healthcare facilities. Minimizes fragmentation in the healthcare system with a focus in coordinating transitions in care by tracking, monitoring and evaluating referrals and obtaining preauthorization when needed. Uphold the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.
This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.
Essential Duties & Responsibilities:
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Maintains regular attendance and punctuality.
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Monitors external referral activities set by PRC, providing quarterly reports to ensure the department is on track to meet necessary measures.
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Provides case management for patients needing referred care from pre-admission to post discharge.
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Works with the patient, family and an interdisciplinary team; develops a care and service delivery plan based on needs of patient, available provider, and financial resources.
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Conducts appropriate concurrent and retrospective reviews on referred care to patients to determine the appropriateness of admission, procedures, and the necessity of continued hospital care.
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Determines medical necessity and appropriateness of level of care using Centers for Medicare & Medicaid Services (CMS) approved criteria for inpatient and outpatient referred care encounters.
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Checks the severity of illness, intensity of service, and discharge criteria on referred patients.
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Refers appropriate cases to the Chief Medical Officer for medical review.
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Screens all referrals for alternate resources and works closely with Business Coordinator and Contract Health Services to maximize the use of alternate resources for referred care payment, protecting PRC funds for those patients who do not qualify for alternate resources.
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Certifies the acute hospital level length of stay for PRC payment and WIHCC utilization purposes.
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Works collaboratively with other departments to coordinate patient needs before discharge, discharge planning activities and continuity of care.
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Determines if services are being delivered as planned and are meeting needs; reassesses, at appropriate intervals, to determine if the patient’s condition or situation has changed, and revises goals and plan of services accordingly.
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Serves as an advocate for the patient and their families.
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Provides in-service training to medical providers/PRC staff to enhance communication.
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Demonstrates ability to build and maintain collaborative relationships with healthcare providers, community organizations, and key stakeholders. Represents the organization at meetings, conferences, and community events to strengthen partnerships and promote organizational initiatives. Position requires occasional travel within the service area and periodic overnight travel for training, conferences, and professional development.
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Requires completion of tasks or duties assigned by a supervisor.
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Upholds all principles of confidentiality and patient care to the fullest extent.
- Adheres to all professional and ethical behavior standards of the healthcare industry.
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Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
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Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
- Possesses cultural awareness and sensitivity.
- Maintains compliance with all Human Resources requirements.
- Performs other duties as assigned.
Minimum Qualifications:
Graduate of accredited school of nursing, Bachelors preferred, Associates Degree considered with advanced Nursing experience. Must be licensed as a Registered Nurse in a State, the District of Columbia, or Puerto Rico. Certification as a Certified Case Manager (CCMC) preferred, candidates without current certification must be eligible to sit for the CCM exam and obtain certification within 18 months of hire. Three years clinical experience and one year of experience in utilization management, discharge planning, or case management. Bilingual skills in English and Navajo language preferred. Must maintain a valid unrestricted and insurable driver’s license. Must successfully pass a background investigation and maintain suitable requirements for a Child Care position. This position is considered as a Child Care position, which requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).
Knowledge, Skills, Ability
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Knowledge of the Managed Care Model of healthcare delivery, including utilization review, medical necessity criteria, clinical pathways, practice guidelines, discharge planning, and case management.
- Knowledge of federal, state, Tribal, and private payer regulations, review requirements, and compliance standards related to healthcare services and Purchased/Referred Care (PRC).
- Knowledge and understanding of Indian Health Service (IHS), Bureau of Indian Affairs (BIA), and Public Law 93-638 Tribal healthcare programs and operations.
- Knowledge of applicable legislation affecting Purchased/Referred Care programs, including the Purchased and Referred Care Improvement Act and Protecting Native Americans’ Credit Act.
- Knowledge of healthcare operations, medical procedures, and patient/provider needs throughout all phases of treatment and care coordination.
- Knowledge of confidentiality requirements, including HIPAA regulations and patient privacy standards.
- Knowledge of service area demographics, socioeconomic factors, and barriers that impact healthcare access and outcomes.
- Knowledge of cultural competency principles and sensitivity to cultural, linguistic, and socioeconomic differences.
- Knowledge of customer service principles, professional ethics, integrity, and workplace conduct.
- Knowledge of conflict resolution techniques and complaint management processes involving patients, staff, vendors, and external stakeholders.
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Knowledge of strong work ethics in the workplace.
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Knowledge of duties and responsibilities of the position.
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Skill in critical thinking, strategic planning, and decision-making.
- Skill in analyzing complex problems, projecting consequences, identifying solutions, and implementing effective recommendations.
- Skill in conducting audits, and review of charts utilizing investigative techniques, with strong attention to detail and accuracy.
- Skill in leadership, staff development, coaching, mentoring, and performance management.
- Skill in creative problem-solving and process improvement.
- Skill in verbal and written communication, including proper grammar, spelling, punctuation, and professional correspondence.
- Skill in establishing and maintaining effective working relationships with healthcare providers, vendors, referral facilities, and community partners.
- Skill in customer service and interpersonal communication.
- Skill in the use of computer applications including Microsoft Outlook, Word, Excel, PowerPoint, and other healthcare information systems.
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Ability to interact positively with others and possess great interpersonal skills.
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Ability to learn, navigate, and effectively utilize healthcare information systems and databases, including RPMS, EHR platforms, HIE systems, Cerner, Epic, McKesson, AHCCCS portals, Novitasphere, spreadsheets, and related software applications.
- Ability to maintain strict confidentiality and protect sensitive patient, employee, and organizational information.
- Ability to communicate effectively both orally and in writing with individuals at all organizational levels.
- Ability to provide leadership, delegate responsibilities, train staff, and evaluate employee performance.
- Ability to establish rapport and interact effectively with individuals of diverse cultural, educational, and socioeconomic backgrounds.
- Ability to represent WIHCC's Mission, Vision, and Values while providing exemplary customer service.
- Ability to network and maintain collaborative relationships with external healthcare facilities, vendors, and community organizations to improve patient outcomes.
- Ability to multitask, prioritize workload, and perform effectively in a fast-paced environment under pressure.
- Ability to exercise sound independent judgment and work with minimal supervision after orientation and training.
- Ability to adapt to changing organizational priorities, processes, and healthcare regulations.
- Ability to accept constructive feedback and apply recommendations for professional growth and performance improvement.
- Ability to demonstrate professionalism, reliability, punctuality, dependability, and accountability in attendance and job performance.
- Ability to meet attendance, overtime (if necessary), and other reliability requirements of the job.
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Ability to function effectively as a collaborative team member while maintaining self-confidence and initiative.
- Ability to exercise tact, diplomacy, and professionalism when addressing sensitive or difficult situations.
Physical Demands:
While performing the essential functions of this position, the employee is regularly required to walk, sit, use hands and fingers, handle, or feel objects and equipment, reach with hands and arms, and communicate effectively by talking and hearing. The employee frequently must stand, climb, balance, stoop, kneel, crouch, or crawl and may occasionally use taste or smell. The employee must occasionally lift and/or move objects weighing up to 50 pounds.
Work Environment:
Work is performed in an office setting or outdoor work environment with a moderate noise level. Work environment may involve exposure to physical risks, such as blood borne pathogens, hazardous chemicals, or operating dangerous equipment, and requires adherence to all safety protocols. Required work schedules may include evening, weekend, overnight shifts, extended hours, or irregular schedules as operational needs dictate.
As required by P.L. 93-638, absolute preference will be given to qualified Navajo applicants. If there is no qualified Navajo applicant, preference will be given to qualified American Indian applicants.
