Employment Opportunities
Director, Purchase Referred Care (PRC)
This position has been filled.
Public?:
Internal
Division:
Health
Reports To:
Medical Director
Type of Position:
Regular Full Time
Location:
Little Axe Health Center / 15951 Little Axe Dr. / Norman, OK 73026
General Description |
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The Director of PRC Programs provides support services for clients in the AST Health System, a tribally operated healthcare facility, by serving contracting healthcare services that would otherwise not be available. The PRC program provides a mechanism of payment for services purchased in the private sector and ensures that payments are made accurately and timely. The PRC Program is integral to providing comprehensive health care services to American Indians and Alaska Natives (AI/AN).
The IHS health system delivers care through direct care services provided in IHS, tribal, and urban (I/T/U) health facilities (e.g., hospitals, clinics) and through PRC services provided by non-IHS providers. The general purpose of PRC is for IHS and tribal facilities to purchase services from private health care providers in situations where: 1) no IHS or tribal direct care facility exists; 2) the existing direct care element is incapable of providing required emergency and/or specialty care; 3) utilization in the direct care element exceeds existing staffing; and 4) supplementation of alternate resources (e.g., Medicare, Medicaid, or private insurance) is required to provide comprehensive health care to eligible AI/AN. The combination of an increasing AI/AN population, limited funding, medical inflation, and limited competitive pricing and options requires strict adherence to program guidelines to ensure the most effective use of PRC resources. These guidelines apply to qualifying factors such as medical priorities of care and eligibility requirements that are more stringent than those for IHS direct care.
The AST Health System’s PRC Director assures compliance with all program requirements are met by subordinate personnel in servicing tribal patients in a timely, sensitive manner. Director shall maintain a centralized medical and dental (as well as other appropriate referrals for care) in a referral system and will be responsible for coordinating all patient referrals and follow ups, working closely with the medical staff and Contract Health. Incumbent serves as an advocate for patients being referred for outside services. The PRC shall ensure appropriate back up to the other PRC Coordinators with the purchase order system. All financial related transactions are subject to review/approval by the executive director or their designee.
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Responsibilities |
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• Oversees the PRC program in its entirety with the support of the Executive Director and other health program key staff.
• Maintain accurate patient records through documentation for PRC specific and other patient/client files.
• Coordinate patient/client referrals necessary to fulfill PRC requirements and guidelines.
• Ensure patient/client access and signing up to health insurance programs.
• Assures crucial leadership on the ACA Sponsorship programs with administration and other key staff offices/employees.
• Ensures all appropriate documentation and timely submission of Catastrophic Health Emergency Fund (CHEF) cases are completed.
• Leads the Case Conference Medical Review (CCMR) process; liaisons with leadership and Medical Director on addressing medical necessity of cases reviewed for approval of payment based upon compliance with program directives and proper compliance.
• Facilitate negotiations and payments on behalf of PRC eligible patients and clients. Advocates PlusCare after-hours program usage in training to tribal members and production of materials for marketing and advertising to decease emergency utilization (within proper protocols and in line with Policies and Procedures).
• Maintain database for accurate accounting of patients and clients.
• Provide accurate records for expenditures relevant to the health program especially the PRC program.
• Provide written and statistical reports for specific grant requirements and compliance.
• Other related duties as directed by the Executive Director to support the goal of the Health programs and its’ success including reports, attending meetings such as General Council, health fairs, and other tribal events to promote health and PRC programs.
• Ensures proper coordination of referrals and appointments with medical specialists, including determining patient’s health care payment and eligibility resources; but not limited to: Obtaining all insurance pre-authorizations necessary for the referral; sending all medical notes, demographics, and billing information to the outside vendor; tracking the patient appointments to completion; arranging for transportation if needed; following up with the outside vendors to ensure patient records are received at our facility; and ensuring the patient has proper follow-up until medical care is complete.
• Maintains compliance with Indian Health Services PRC/Contract Health Services program regulations and AST Health System program policies and procedures to include the maximum utilization of alternate resources.
• Works closely with business office, health center providers/Medical Review Team to ensure that all external medical/dental professional referrals are medically appropriate and within medical and dental priority.
• Makes appointments and issues purchase orders (PO) for patients being referred outside of the AST Health System; coordinates with Admin, the Business Office, and the Patient Benefits Advisor to determine CHS eligibility and payment of POs.
• Maintains accurate and current electronic record keeping system for PRC program.
• Participates in QI health department meetings, program planning, evaluations & improvement strategies to minimize problems and optimize operation efficiency. Participates in and supports the compliance and quality assurance programs.
• Ability to communicate and work effectively with people from diverse socioeconomic backgrounds and education levels.
• This position requires dual-site supervision of PRC program offices located at both LittleAxe and Shawnee Clinics.
• Some travel required for training sessions and conferences.
• Other duties as approved and assigned by the Executive Director, Multi-Site Clinic Administrator, and/or Medical Director.
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Posted Date:
1 year 3 months ago