PRC Director - Purchased Referred Care

Prc Program Manager

Design, implement, and manage the PRC program that addresses the specific specialty healthcare needs of the Wind River Reservation. Provides leadership and oversight to the PRC program and teams. Ensures development of PRC initiatives to improve patient satisfaction and family centered care. Collaboration with other internal departments and external specialty vendors for PRC program initiatives. Leads and / or serves on a variety of appropriate internal and external committees to represent Wind River Family and Community Health Care (WRFCHC) PRC program. Reviews, analyzes, and summarizes pertinent financial, statistical, and program data. Develops yearly PRC spending plan to maximize the funds allocated to PRC for each Fiscal Year. Maintains weekly fund status reports to provide current PRC funding level to Administration. Prepares monthly reconciliation reports, identifies and corrects discrepancies on payments and adjustments. Responsible for reporting of Catastrophic Health Emergency Fund (CHEF) cases, working closely with PRC staff, medical staff, IHS office staff, and Claims Management Program to report, manage, and monitor high cost cases funded through the CHEF program. Monitors all unpaid open documents (pended) received from Claims Management Program, working closely with the vendors and providers to resolve. Provides administrative and technical supervision to the PRC department staff by preparing schedules, assigning work based on needs of the department, advising, coaching, or issuing disciplinary action, and completing evaluations per WRFCHC Human Resource's policy. Develops, coordinates and integrates operational plans in accordance with approved policies and directives pertinent to the administration and management of the WRFCHC PRC program requirements (eligibility, payer of last resort, residency, etc.) Prepare and present reports on program progress to executive management. Research, develop, write, update, and implement PRC policies, standard operating procedures, competencies, and checklists in compliance with relevant laws, regulations, and organizational standards. Participates in the weekly PRC referral review committee meetings. Works with supervisor / CEO in establishing vendor contracts for Medicare Like Rate (MLR) agreements. Reviews walk-through (emergent) referrals on an as needed basis. Approves or denies referrals based on administrative eligibility criteria. Establishes and maintains mechanisms for assuring that patients register for benefits for which they may be eligible to ensure WRFCHC PRC program is a payer of last resort for referred services. Manages appeals and denials at the local (WRFCHC) level with assistance from the PRC staff. Assists with compiling training materials regarding the PRC process for internal and external stakeholders. Trains vendors, interdisciplinary staff / departments on the PRC process, regulations, administrative processes, and other training needs. Engages staff and other stakeholders in continuous improvement of systems and processes; manages resources for staff participation in improvement of PRC department work activities. Responsible for timekeeping of designated PRC staff in accordance with WRFCHC Policies and Procedures. Assist with hiring procedures and interviews of new staff for the PRC department. Assists with presentations on PRC program requirements to patients, vendors, other agencies, and the general public as needed to ensure thorough understanding of the PRC program. Other duties as assigned to maintain and enhance the operation of the department.