Job Description

Level: Experienced
Job Location: Dilkon Medical Center - Dilkon, AZ 86047
Position Type: Full-TimeEducation
Level: Bachelors Degree
Travel Percentage: Occasionally
Job Shift: DayUnder general supervision of the Purchased Referred Care (PRC) Supervisor, provides utilization review and case management for patients referred with complex, high-risk health issues, such as cancer, organ transplants, heart failure, etc. Understanding of how numerous medical, insurance, government and employer-related factors affect healthcare delivery systems and patient outcomes. Minimizes disruptions in the healthcare system, with a focus in coordinating transitions of care by tracking, monitoring and evaluating referrals. Obtaining preauthorization of treatment services and assisting in the appeals process of denials when needed. Uphold the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.
This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:
- Maintains regular attendance and punctuality.
- Monitors high-risk referral activity, providing case management outcomes data to ensure the department is on track to meet necessary measures.
- Analyzes case management outcomes data: quality and cost.
- Provides case management for patients needing referred care, facilitates multiple consults with specialty vendors for complex, high-risk cases.
- Acts as a liaison between patients, family and interdisciplinary team.
- Serves as an advocate for the patient and their support system.
- Participates in the process of assessment, planning, facilitating, monitoring and evaluation of options and services to meet an individual patient’s health care needs.
- Develops a care and service delivery plan based on needs of patient, available provider, and financial resources.
- Confirms consults and plan of care are medically appropriate and adhere to the Standards of Care.
- Determines if services are delivered as planned and are meeting needs; reassesses, at appropriate intervals, to determine if the patient’s condition or situation has changed, and completes all documentation in accordance with the policies and procedures
- Identifies complex issues: Social Determinant of Health, health literacy, etc.
- Refers appropriate cases to the Chief Medical Officer for medical review.
- Screens patients for alternate resources, works closely with Patient Benefits Coordinators to maximize the use of alternate resources for referred care payment and protects PRC funds for those patients who do not qualify for alternate resources.
- Determines PRC eligibility through review of the six criteria while adhering to WIHCC PRC policy and IHS regulations.
- Interfaces with insurance carriers and billing departments to initiate appeals and obtain authorizations for treatments.
- Support and coordinate the activities of the Case Managers within the department
- Supports, assists and delegates to Purchase Referred Care staff (Health System Specialists, Contact Representatives and Support Assistants).
- Assists Primary Care Physician to ensure the patient's high-risk complex medical and psychosocial needs are met.
- Assist providers with diagnosis codes and medical necessity requirements when required for insurance purposes.
- Promotes wellness in accordance with the Population Health Management model by directing members to PCP and educating members regarding health and wellness measures.
- Communicates with physicians and clinical staff regarding ongoing patient care.
- Assures high quality, cost efficient medical outcomes for patients identified as high-risk (transplant, cancer)
- Works collaboratively with other departments and vendors to coordinate patient needs, payment authorizations and continuity of care.
- Networks with outside vendors to establish professional relationships and enhance the referral process and patient outcomes
- Provides in-service training to medical providers/PRC staff to enhance communication.
- Requires completion of tasks or duties assigned by a supervisor.
- Adheres to all professional and ethical behavior standards of the healthcare industry including Codes of Professional Conduct, when applicable, pertaining to professional licensing, certification and credentialing bodies (AZ Board of Nursing, Commission for Case Manager Certification, etc.).
- Adheres to all state and federal laws and regulations, with knowledge of legislative and regulatory changes, includes but is not limited to Centers for Medicare and Medicaid Services (CMS), Health Insurance Portability and Accountability Act (HIPAA), Americans with Disabilities Act (ADA), Emergency Medical Treatment and Labor Act (EMTALA) and the Arizona Board of Nursing.
- Maintains accountability to professional licenses and certifications and stays within the scope of practice and responsibilities.
- Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
- Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
- Maintain appeal records. Advises CEO and CMO regarding PRC denials and appeals.
- Recommends the approval and disapproval of funding request, obligations and expenditures of funds on the basis of interpretations of laws, regulations or policy and status of funding.

QualificationsMinimum

Qualifications:
Must be a graduate of an accredited school of nursing and must hold an active and unencumbered AZ RN License or Compact State Licensure. Bachelor’s degree in nursing or related field required. Certification in case management preferred or willingness to become certified when eligibility of the certification governing board is met. Ten years acute care experience required, five years of specialty experience (oncology, ICU, surgery, ER, etc.) preferred, and two years of experience in utilization management, discharge planning, or case management required. Bilingual skills in English and Navajo language preferred. Must maintain a valid unrestricted and insurable driver’s license. Must successfully pass a background investigation and maintain suitable requirements for a Child Care position. This position is considered a Child Care position, which requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).
Knowledge, Skills, Ability
- Knowledge of case manager roles and responsibilities, and understanding of the importance in Joint-Commission-accredited organizations because they are crucial to accreditation.
- Knowledge of care delivery and reimbursement methods.
- Knowledge of case management models, regulations and standards of practice.
- Knowledge of federal, state and tribal legislation and regulations.
- Knowledge of how to navigate multiple systems such as RPMS, Netscaler, HIE, Epic, Cerner, Carelink, Mckesson, Novitasphere, AHCCCS, etc.
- Knowledge of Purchase Referred Care Program.
- Knowledge of Medicare and Medicaid programs.
- Knowledge of diagnosis codes, procedure codes and DRGs.
- Knowledge of prior authorization, appeals process and medical necessity.
- Knowledge of and sensitivity to cultural and language differences.
- Knowledge of strong work ethics in the workplace.
- Knowledge of Evidence Based Practice in regards to case management, disease processes, and treatments.
- Knowledge of basic computer skills.
- Skills in decision-making and independent judgment.
- Skills in creative problem solving and leadership.
- Ability to research and provide guidance on laws, regulations and nursing practice.
- Ability to meet attendance, overtime (if necessary), and other reliability requirements of the job.
- Ability to provide exemplary customer service at all times.
- Punctual, reliable and dependable in attendance and job performance.
- Strong communication skills both verbal and written i.e., proper pronunciation, spelling, grammar, punctuation, and basic arithmetic
- Ability to maintain HIPPA guidelines and confidentiality.
- Heightened integrities and strong work ethics
- Advanced knowledge in Outlook, Word, Excel, PowerPoint.
- Critical thinking and strategic planning capabilities
- Skill in analyzing problems, projecting consequences, identifying solutions, and implementing recommendations.
- Provides leadership, delegation, training, and evaluation to assigned staff.
- Interacts effectively with individuals of all cultural and socioeconomic backgrounds, experience and education levels.
- Demonstrates knowledge and understanding of the Bureau of Indian Affairs’ 638 tribal facilities.
- Demonstrates knowledge of S.3797 - Purchased and Referred Care Improvement Act and H.R.7515 - Protecting Native Americans’ Credit Act of 2024
- Represent WIHCC Vision, Mission and Values while providing exemplary customer service.
- Ability to interact positively with others and possess great interpersonal skills.
- Ability to multitask and perform well under pressure.
- Ability to have self-confidence.
- Ability to be a great team player.
- Ability to accept and learn from supervisor/peer critique.
- Ability to be flexible and adaptable to the changing needs of the organization.
Physical Demands:
While performing the essential functions of this position, the employee is regularly required to walk, sit, use hands to handle and manipulate objects and equipment, reaches with hands and arms, and communicate effectively verbally and audibly. The employee frequently must stand, climb, balance, stoop, kneel, crouch, or crawl and may occasionally use taste or smell. The employee must occasionally lift and/or move objects weighing up to 25 pounds.

Work Environment:
Work is performed in an office setting or outdoor work environment with moderate noise levels. Work environment may involve exposure to physical risks, such as blood borne pathogens, hazardous chemicals, or operating potential dangerous equipment, and requires adherence to all safety protocols. Required work schedules may include evening, weekend, overnight shifts, extended hours, or irregular schedules as operational needs dictate.
As required by P.L. 93-638, absolute preference will be given to qualified Navajo applicants.  If there is no qualified Navajo applicant, preference will be given to qualified American Indian applicants.