Purchase and Referred Care Manager

The-Coquille-Indian-Tribe; Coos Bay (OR); In loco; USD 90.000 - 120.000; Tempo pieno

Descrizione del lavoro

The Coquille Indian Tribe seeks a seasoned professional to oversee Purchased & Refere d Care (PRC) administration within the Health & Wellness Division. This role leads the PRC Registration Specialist, guiding budgets, audits, and policy development to ensure compliant, efficient service delivery.

Responsibilities include program administration, claims auditing, and stakeholder coordination, with travel as needed to support tribal healthcare operations and partnerships.

Competenze

• Strong leadership and supervisory experience in public health/medical outpatient settings.
• Knowledge of Medicaid/Medicare and private health insurance.
• Familiarity with HIPAA privacy and confidentiality guidelines.
• Ability to develop budgets, contracts, grants, and program evaluation.
• Current driver’s license in good standing.

Mansioni

• Coordinate and oversee PRC Registration activities and PRC data systems.
• Administer the PRC program including pre-authorizations, pre-obligations and denials.
• Audit claims for payments and pursue alternate resources.
• Develop and administer budgets and grant reporting for the Health & Wellness Division.
• Collaborate with IT and external partners to ensure efficient system work processes.

Conoscenze

Verbal communication

Written communication

Team building

Problem solving

Interpersonal skills

Budget management

Grant administration

Decision making

Stakeholder management

Formazione

Associate’s degree in Public Health or related field

Descrizione del lavoro

SUMMARY OF MAJOR FUNCTIONSThe Coquille Indian Tribe operates the Ko-Kwel Wellness Center (KWC) and Shishda Haws Rehabilitation & Fitness Center to provide comprehensive, culturally responsive healthcare, rehabilitation, wellness, and prevention services to the Coquille Indian Tribe community.Under the direct supervision of the PRC and Registration Manager this position coordinates and facilitates the administration of Purchased & Referred Care (PRC) for the Health & Wellness Division (HWD).ESSENTIAL DUTIES AND RESPONSIBILITIESProvides leadership and oversight to the PRC Registration Specialist. Increases management effectiveness by hiring, orienting, and training staff; assigning and delegating work; reviewing and evaluating performance; coaching and providing feedback; and assisting with disciplinary measures as necessary.Assists with development and implementation of budgetary processes.Administers the PRC program; maintains PRC data systems and data utilization in program operations. Issues denial letters for noncompliance with PRC program. Pursues use of alternate resources. Audits claims for payments. Pre-authorizes, pre-obligates, and approves PRC funds to all healthcare providers. Maintains PRC social media, mailings, and reports.Drafts PRC policy and procedure modifications for presentation to advisory and governing bodies.Maintains PRC data systems and data utilization in program operations.Issues denial letters for noncompliance with PRC program.Pursues use of alternate resources.Functions as an Oregon Health Authority Medicaid Community Partner.Audits claims for payments.Pre-authorizes, pre-obligates, and approves PRC funds to all healthcare providers.Maintains PRC social media, mailings, and reports.Frequently engages with PRC enrollees to offer support.Managing the electronic payment and processing systems.Manages, maintains, and files appropriate Catastrophic Health Emergency Funding cases with Indian Health Services.Manages Retiree Subsidy Drug Program for maximum rebates and revenue.Administers the Tribal Premium Sponsorship Program and provides Medicare premium reimbursements to eligible Tribal members.Negotiates discounts with vendors and providers.Collaborates with vendors to provide care and case management for patients.Develops and maintains a thorough understanding of PRC policies and procedures.Coordinates with IT health information personnel to improve and maintain accurate administration of system work processes, claims submissions, and logistics.Coordinates and conducts Resource Management Committee meetings.Manages the Medicare Like Rates (MLR) repricing program and provide reports as required.Other duties as assigned.The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified and should not be considered as a detailed description of all work requirements that may be inherent in the job. This position may involve transporting Native Americans and Non-Native patients and clients in Tribal vehicles, employee-owned vehicles and rental vehicles to and from a variety of KWC Eugene functions and activities.PHYSICAL REQUIREMENTSRequires the ability to communicate orally, repetitive movement of the wrists, hands and/or fingers, often requires walking, standing, raising or lowering objects, and occasionally requires lifting up to 25 pounds. Requires occasional sitting. Work is generally performed in an office setting and outdoors. Occasional evening and weekend work are required. Will often be required to travel by automobile, commercial or private carrier. Local travel is frequently required; statewide and national travel is occasionally required. The individual must perform the essential duties and responsibilities with or without reasonable accommodation efficiently and accurately without causing a significant safety threat to self or others.REQUIRED KNOWLEDGE, SKILLS, AND ABILITIESThe individual must be able to perform the essential duties and responsibilities of the position safely, efficiently, and accurately. Work duties or processes may be modified, when appropriate and feasible, to support successful performance without creating a significant safety riskExcellent verbal and written communication skills with strengths in team building, and cooperative problem solving. Ability to consistently convey a pleasant and helpful attitude by using excellent interpersonal and communication skills to control sometimes stressful and emotional situations.Ability to foster an inclusive workplace where diversity and individual differences are valued and leveraged to achieve the vision and mission of the Coquille Indian Tribe.Ability to develop the skills of others to perform and contribute to the organization by providing ongoing feedback and by providing opportunities to learn through formal and informal methods.Demonstrated ability to be results driven; making decisions that produce high-quality results by applying technical knowledge, analyzing problems, and calculating risks.Knowledge and skill in performing department-level administrative functions, including personnel and budget management, procurement, preparation and administration of contracts, grants and agreements and program evaluation and reporting.Ability to maintain effective working relationships with outside government officials, administrative and granting agencies.Ability to successfully carry out all phases of grant administration including writing grant applications, developing, and tracking budgets, and grant reporting.Ability to read and understand technical documents and manuals, as well as the ability to write such documents for use by others.Be computer literate. Exhibit a level of computer literacy sufficient to use software such as word processing, spreadsheets, and databases to produce correspondence, documents, and reports.Ability to maintain professionalism, confidentiality, and objectivity under constant pressure and crisis situations. A breach of confidentiality or fraud is grounds for immediate dismissal.REQUIRED QUALIFICATIONSAssociate’s degree in Public Health, Healthcare Administration, Business or a related field; or an equivalent combination of education and experience may be considered.Three (3) years of management and supervisory experience in a public health or medical outpatient setting is required.A combination of formal education, training, and related work experience may be considered.Knowledge and experience in including working with Medicaid, Medicare and private health insurance Is requiredKnowledge of HIPAA privacy and confidentiality guidelines is required.Current and valid driver’s license in good standing is required with no insurability restrictions from the Tribe’s insurance carrier.Required to accept the responsibility of a mandatory reporter of abuse and neglect of infants and children, people who are elderly or dependent, individuals with mental illness or development disabilities or residents of nursing homes and other health care facilities. This includes reporting any evidence of physical injury, neglect, sexual or emotional abuse or financial exploitation.First Aid/CPR certification required or ability to obtain within 90 days of employment.PREFERRED QUALIFICATIONSKnowledge of Indian Health Service and Purchase and Referred Care is preferred.Knowledge and experience with Quality Improvement and Accreditation preferred.Experience in health insurance or managed care preferred, especially claims processing.Experience working within a Tribal environment is preferred.