Purchased and Referred Care Director

Ketchikan Indian Community - Purchased and Referred Care Director

Location: Ketchikan, AlaskaJob Title: Purchased and Referred Care DirectorDate Posted: 06/18/2024Type of Job: Full TimeAnticipated Job Duration: Year RoundJob DescriptionIndian 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.PurposeThe 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 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.Job Duties & ResponsibilitiesMaintain a culturally responsive PRC department through staff training and adherence to policy and procedures.Coordinate patient/client referrals necessary to fulfill PRC requirements and guidelines.Ensure patient/client access to health insurance programs.Facilitate negotiations and payments on behalf of PRC eligible patients and clients.Provide accurate records for expenditures relevant to the health program, especially the PRC program.Monitor PRC operation budget and submit written requests for supplemental PRC funds if necessary.Oversee the authorization and processing of medical referrals to external providers.Monitor and evaluate program effectiveness and make improvements as needed.Manage the PRC budget, ensuring cost-effective use of funds.Facilitate PRC Committee to develop, monitor, and enforce financial policies and procedures.Distribute monthly funds status reports of current PRC funding levels to KIC THC Leadership.Oversee payment processes for services provided by external healthcare entities.Develop and implement quality assurance programs to monitor service quality and patient outcomes.Conduct audits and reviews to ensure program integrity and compliance.Collaborate with healthcare providers, hospitals, and other agencies to coordinate patient care.Ensure timely access to necessary medical services for patients referred outside of IHS facilities.Address issues related to service delivery, patient satisfaction, and quality of care.Provide PRC onboarding and annual training to providers and support staff.Responsible for reporting potential cases for the Catastrophic Health Emergency Fund (CHEF).Maintain partnership, MOAs, Agreements, and/or contracts with third-party payors and clearinghouses.Responsible for establishing and maintaining KIC THC PRC department and administrative policies.Conduct community outreach and education regarding PRC funding and eligibility criteria.Maintain appeal records files in keeping with the appeal process contained in Federal regulations or policies.Develop and propose effective department guidelines in keeping with approved Tribal Council Policies and Ordinances.Perform other duties as assigned.Minimum Qualifications (Education & Experience)Bachelor’s Degree in health-related or business field.Three years progressive administrative management experience in third party administration or related field.A combination of relevant experience, education, and training may substitute for education and experience requirements on a year-for-year basis.Working ConditionsThe 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.KIC is a Drug-Free Workplace. All employees must adhere to KIC drug and alcohol policies and procedures to ensure a safe workplace.Conditions of HireMay be required to possess and maintain a valid driver's license or capable of obtaining one.Must pass a pre-employment and subsequent random and/or for cause drug and alcohol screening.All employment offers in the

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