Indian Preference: In accordance with the Indian Preference Act of 1934, application for the position must include documentation of Tribal Enrollment.
Purpose
Ketchikan Indian Community (KIC) job descriptions are a management tool to help organize duties and provide employees with the employer’s expectations with regard to a specific job classification. The duties listed are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is a reasonable assignment for the position. This job description is not an employment agreement or contract. Management has the exclusive right to alter this job description at any time without notice.
Job Summary
Incumbent is responsible to manage and coordinate the Purchased and Referred Care (PRC) operations. Activities included are case management of direct patient care services and technical assistance to the PRC staff regarding matters involving referrals, specialty and inpatient health care and alternative health care resources for all eligible beneficiaries in conjunction with or in lieu of Indian Health Care facilities.
Maintains performance improvement activities within the department and participates in Accreditation Association for Ambulatory Health Care (AAAHC) activities; assists in management and direction of the department administrative and financial functions. Incumbent is responsible for direction and supervision of the Alternate Resource/Benefits Coordinator and Purchased and Referred Care Technicians.
ESSENTIAL SUPERVISORY JOB FUNCTIONS
COMPLETES OPERATION BY:
- Developing schedules, assigning and monitoring work; gathering resources; resolving operations problems; maintaining reference manuals; implementing new procedures.
- Promoting a motivational environment that maintains the department as a cohesive unit.
- Investigating, evaluating, and recommending PRC supplies and equipment;
- Recruiting, selecting, orientating, and training Alternate Resource/Benefits Coordinator and Purchased and Referred Care Technician positions.
MAINTAINS STAFF BY:
- Recruiting, selecting, orientating, and training employees;
- Maintaining a safe working environment;
- Developing personal growth opportunities.
ACCOMPLISHES STAFF JOB RESULTS BY:
- Communicating job expectations;
- Coaching, counseling, and disciplining employees;
- Planning, monitoring, and appraising job results;
- Conducting training, implementing and enforcing systems, policies, and procedures;
- Informing employees at least weekly or as necessary of all matters affecting their employment;
- Providing tools and equipment necessary for staff performance accountability.
Essential PRC Manager Job Functions
ASSISTS SUPERVISOR BY
- Assisting in workload distribution among coworkers;
- Providing assistance to coworkers as necessary;
- Monitoring and reviewing coworker’s progress;
- Assisting in training of new employees;
- Assuming supervisory duties during his/her absence.
RESOLVES PROBLEMS BY
- Addressing complaints regarding PRC Department functions and works with supervisors to resolve;
- Attending and participating in appropriate administrative and committee meetings.
- Case management of patient to referring facilities.
MONITORS ELIGIBILITY REQUIREMENTS BY
- Assisting staff with eligibility verification;
- Reviewing Alternate Resource Screening applications;
- Distributing denial letters;
- Reconsidering appeal letters;
MAINTAINS REFERRAL PROCESS BY
- Monitoring all Peace Health/other referral hospital KIC eligible admissions;
- Monitoring all non-Ketchikan health care facility referrals;
- Informing clinical and administrative coordinators of questionable utilization of inpatient/outpatient facility;
- Monitoring authorized financial obligations;
REVIEWS FINANCIAL OBLIGATIONS BY
- Collecting and recording all information of admissions, Emergency Room visits, referrals, and diagnostic tests required to make an informed decision;
- Reviewing weekly Alternate Resource Screening reports, encumbrance reports, and financial spreadsheets;
- Submitting final obligation payments as outlined in department policy and procedure;
- Notifying Finance Department of appropriate budget line item assignment;
- Reviewing detail budget reports.
UTILIZE CATASTROPHIC HEALTH EMERGENCY FUNDS (CHAP) OR THE TRIBAL SPONSORED HEALTH INSURANCE PROGRAM (TSHIP) BY
- Monitoring and tracking potential CHAP or TSHIP cases;
- Maintaining CHAP/TSHIP spreadsheet;
- Identifying over/under payments by KIC.
PERFORMING LIAISON ACTIVITIES BY
- Monitoring in conjunction with KIC’s Case Management Nurse and appropriate facility personnel the admittance and discharge of patients;
- Communicating with professional and paraprofessional health care providers in hospitals, outpatient clinics, and community-based organizations;
- Assuring a smooth transition from inpatient care to recuperation and optimal health in an outpatient setting;
- Communicating with patient and patient’s family in education and information related to PRC Committee decisions and implementation.
FOLLOWS GUIDELINES BY
- Including procedures established by the Clinic’s Managed Care Plan that have been approved by medical staff;
- Adhering to AAAHC Standards;
- Adhering to the criteria developed by PRO/W-APRO.
- Developing new methods in the absence of appropriate guidelines.
- Adhering to KIC policy and procedures for the PRC programs
- Complete understanding of CFR 42 and Indian Health Service regulations for the PRC program
MAINTAINS QUALITY RESULTS BY
- Participating in the quality assurance program;
- Assisting staff with ideas for ways to improve PRC operations;
- Consulting with Clinic Department Directors, clinical and technical consultants;
- Performing proficiency surveys;
- Making adjustments in policy and procedures;
- Generating reports;
- Maintaining records.
IMPLEMENTS NEW PROGRAMS, METHODS, AND PROCEDURES BY
- Leading the PRC staff in quality improvement team including documenting minutes;
- Investigating alternatives;
- Preparing proposals;
- Monitoring progress.
PREPARES MONTHLY PRC OPERATION REPORTS BY
- Collecting, analyzing, and summarizing information and trends;
- Monthly budget review
Essential Administrative Job Functions
MAINTAINS PRC EQUIPMENT BY
- Establishing quality standards;
- Inspecting and evaluating the physical condition of the department areas, recommending necessary changes to Maintenance to improve sanitation, appearance, and efficiency;
- Developing operations, quality, and troubleshooting procedures;
- Ensuring staff compliance;
- Arranging equipment replacement, service, and repair.
MAINTAINS PRC SUPPLIES INVENTORY BY
- Checking stock to determine inventory level;
- Anticipating needed supplies and associates costs;
- Placing and expediting orders for supplies;
- Verifying receipt of supplies.
MAINTAINS PRC INFORMATION SYSTEM BY
- Identifying information needs and problems;
- Recommending improvements;
- Establishing priorities;
- Coordinating improvements with IT;
- Testing;
- Writing user manuals
- Training employees;
- Maintaining security and confidentiality.
ACHIEVES FINANCIAL OBJECTIVES BY
- Anticipating requirements;
- Submitting information for budget preparation in cooperation with supervisor;
- Developing Purchased and Referred Care budget annually;
- Monitoring costs and analyzing expense variances;
- Initiating corrective action;
- Monitoring program staffing levels;
MAINTAINS SAFE WORKING ENVIRONMENT BY:
- Reporting any unsafe conditions to appropriate supervisor upon discovery.
- Complying with federal and state laws and regulations regarding the protection of the health of employees and provide for appropriate occupational health services for those employees
MAINTAINS QUALITY IMPROVEMENT PROCESS BY
- Understands the Tribe’s and employees needs by demonstrating courtesy, diplomacy and tact during interactions with internal and external parties;
- Prepares and monitors indicators for quality and continuous improvement;
- Demonstrates continuous initiatives for improvement of PRC operations;
- Takes a systems approach to problem solving and process improvement, which involves staff.
CONTRIBUTES TO TEAM EFFORT BY:
- Participating in the appropriate patient care services committees and other workgroups;
- Conducting interdisciplinary workshops/continuing education programs that promote the knowledge and appreciation of process and value of discharge planning and manage cared or other areas of special interest as identified by supervisor;
- Initiating and directing training programs and in-services for new employees;
- Performing other related duties as directed by supervisor.
MAINTAINS PROFESSIONAL AND TECHNICAL KNOWLEDGE BY
- Conducting research to improve PRC operation technology.
- Attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices.
Additional Job Duties:
- Being accessible to staff for consultation as needed;
- 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;
- Recognize, identify, and resolve problems and issues without direct supervision;
- Maintain accreditation requirements under the direction of the Health Administration;
- Provide instruction to other employees of this or similar job classification in all aspects of procedure and technique relating to the duties required by this job description unless such instruction requires a specialized certification which the employee doing the training does not have;
- Provides information to customers by answering questions and requests.
KNOWLEDGE, SKILLS, AND ABILITIES
- Knowledge to gather, organize, and analyze information for PRC operations and personnel;
- Knowledge of Managed Care/PRC principles and Third-party billing systems; i.e., Medicare, Medicaid, Title XIX, and private insurance carriers;
- Knowledge of medical terminology, ICD9-CM and CPT Coding;
- Knowledge of surgical procedures and commonly seen medical diagnosis in conjunction with historical data relating to specific ward, surgical procedures, and diseases so as to estimate probable length of stay;
- Knowledge of the interrelationship and interdependence among various medical and administrative services and programs;
- Knowledge and ability to carry out rules of Health Insurance Portability and Accountability Act (HIPAA), which protects patient rights;
- Knowledge of word processing, spreadsheet, and electronic health record computer application skills;
- Knowledge of office equipment and limited maintenance;
- Skill in writing as would be required for reports, plans, grants proposals, program justifications, etc.
- Skill in advising and consulting with KIC health professionals on referral process and other health professionals concerning medical necessity and appropriateness of admission and treatment;
- Ability to gather, assemble, and analyze facts, draw conclusions and devise solutions to management problems;
- Ability to communicate professionally over the telephone and in person in a positive and clear manner;
- Ability to manage multiple tasks simultaneously including telephone, computer operations and in-person visits;
- Ability to be flexible in order to perform at the highest level as a team player;
- Ability to utilize maximum degree of professionalism and diplomacy with those who may be experiencing a high degree of stress both mentally and/or physically;
- Ability to work independently with minimal supervision and able to prioritize assignments;
Physical Activities Include
Must be able to hear. Specific vision abilities include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Ability to use hands to finger, handle, or operate objects tools, or controls; reach with hands and arms; climb or balance; stoop, kneel, crouch; and taste or smell. Each of the listed activities also requires standing, sitting, walking, bending, and stooping, climbing on stools and ladders, and routinely lifting and carrying items and boxes up to forty (40) pounds.
Writing by hand and using a personal computer. Long hours in front of computer screen. Frequently required to work extended hours. Traveling occasionally, using air and/or water transportation, to out-of-town meetings and functions.
Working Environment
The employee may be exposed to communicable diseases. Safety precautions for employees such as blood drawing for screening of various diseases such as hepatitis, required immunizations, etc. are necessary. The employee is occasionally subject to verbal abuse, threats, and physical violence from angry, hostile, or disgruntled patients and/or family members.
License(s)
Employee must have a permanent full and unrestricted license to practice nursing in the State of Alaska, another state, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States.
Possess current valid State of Alaska driver's license with a record acceptable to KIC’s Insurance carrier.
Education
Bachelor’s degree in nursing, management or health administration. Prefer Bachelor’s degree as a registered nurse with experience in case management. Case Management certification or relevant experience may substitute for bachelor’s degree.
Experience
Prefer three (3) years progressive administrative management experience in third party administration or benefits administration and two (2) years’ experience in case management.
Any combination of related education and/or related experience will be considered if the candidate possesses the demonstrated ability.
Job Type: Full-time
Pay: From $59,599.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Health insurance
- Life insurance
- On-site gym
- Paid time off
- Prescription drug insurance
- Relocation assistance
- Retirement plan
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
Ability to commute/relocate:
- Ketchikan, AK 99901: Reliably commute or willing to relocate with an employer-provided relocation package (Required)
Work Location: In person
