Director Purchased Referred Care

• Directs staff in the overall Purchased Referred Care program and ensures that the eligibility criteria for participation in the program is adhered to, when administering the program.
• Oversees the benefit coordination functions and provides direction to staff who assist patients with enrolment in government-funded medical programs such as Medicare and AHCCCS (Arizona’s Medicaid program).
• Thorough knowledge of Purchased Referred Care and the managed care model of healthcare delivery includes utilization review, pre-admission authorization, concurrent review criteria, discharge planning, and medical terminology.
• Develops the annual operational budget, operating policies and procedures, and programs to educate staff and ensure they are knowledgeable of the Purchased Referred Care program.
• Coordinates and collaborates with other GRHC departments such as Patient Registration, Primary Care, Behavioral Health, Case Management, and the Caring House, to improve communication and understanding of the Purchased Referred Care program. Partners with the American Indian Medical Home Director to provide assistance where needed.
• Maintains strong partner relationships with Gila River Indian Communities, GRIC District Service Centers, Elder Centers, external vendors such as surrounding hospitals, skilled nursing facilities, Durable Medical Equipment Vendors, and providers.
• Monitors the workflow and efficiencies of the Purchased Referred Care and Eligibility process; leverages the use of electronic health record systems to compile statistical data reports that can be used to evaluate and improve the effectiveness of the program.
• Evaluates staff performance by creating and reviewing key metrics, establishes performance goals and provides ongoing coaching and training.
• Develops and implements strategic plans, and quality assurance programs; creates a plan to provide training and educational material so that patients are aware of the Purchased Referred Care program and the eligibility criteria to participate.
• Holds regular Purchased Referred Care committee meetings to review Purchased Referred Care referral requests, determine eligibility for services and approve notifications. Ensures compliance with Purchased Referred Care policies and procedures.
• Utilizes appropriate software programs to accurately track referrals and authorizations issued
• Maintains accurate and updated patient demographic, payer, and tribal enrollment information in Purchased Referred Care systems.
• Review and process claims timely, once reviewed; prepares claims payment reports in adherence to quality and quantity standards in a timely manner for leadership review and decision making strategy.
• Utilizes patient satisfaction survey data, observations, and reports from Customer Service to improve the patient experience and to provide feedback and coaching to staff related to empathy and service excellence.
• Identifies and corrects operational errors and gives appropriate feedback, coaching, and education to staff. Implements quality assurance initiatives and protocols as needed.
• Workforce Management oversight (Staffing plan, work schedules, position requisitions, interviews/selection, productivity and quality monitors, disciplinary actions, staff orientation, evaluation feedback, etc.)
• Periodically audits requests for healthcare referrals in accordance with established medical necessity/priority, eligibility and payer criteria; behavioral health inpatient admissions for the appropriate payer source; reports of closed claims for accuracy of payment in accordance with contract; and payment history reports.
• Partners with Finance department in the annual audits to provide documentation and ensure processes and procedures are in accordance with local, tribal and regulatory entities.
• Directs procedural changes for area to ensure compliance with standards effecting areas develops.
• Meets established objectives and goals in support of GRHC’s goals.
• Performs other related activities as requested.

• A Bachelor's degree in Health Administration, Business Administration, or a related field is required. Candidates with a minimum of 7 years of relevant management experience (e.g., healthcare administration, PRC management) may also be considered in lieu of a degree.
• 3 years healthcare claims processing experience and/or any equivalent combination of PRC education, training, and experience - including HFMA certifications.
• Experience and years of service in a purchase referred care department preferred.
• Knowledge of medical and insurance terminology.
• Current and continuing CPR/AED training and certifications within 1 year in position.
• Exceptionalcommunication,interpersonal,andcustomerserviceskills.

Gila River Health Care