DUTIES AND RESPONSIBILITIES:

Position duties require expert proficiency and knowledge of PRC regulations and best management practices
which can be acquired through a combination of self-study and participation in PRC training. Supervises
compliance with federal PRC regulations and approved Shoshone-Bannock PRC policies and procedures.

Will cross train with each PRC staff person to assess their scope of work and develop written workflow
procedures. The assessment can lead to quality improvement processes and/or gaining the ability to fill in
as necessary to ensure service delivery during an employee’s absence and/or when the program experiences
a high volume of referrals.

Reviews and updates PRC operational policies, procedures, and protocols to ensure timely processing of
referrals, payment of claims, and to monitor utilization outcomes.

Review and assist with referrals. This involves checking eligibility, checking alternate resources and ensuring
appropriate budget for the service.

Works under the direction of the THHS Finance Officer to ensure PRC maintains sound fiscal management
practices. Monitors program budget status to determine if PRC service levels need to be restricted due to
limited funds.

Works closely with the THHS Director and Finance Officer to review and make management decisions based
upon funding projections, reports, relationships with Broker and TPA, budgets, and special projects.

Oversee that all Catastrophic Health Emergency Funds (CHEF) cases are submitted accurately and timely
and reporting this information to the THHS Finance Officer. Works with Benefits Coordinator to ensure PRC
eligible patients secure required alternate resources to meet regulatory requirements aligned with PRC payer
of last resort and/or to ensure the high cost claims qualify for CHEF re-imbursement.

Develops and implements cost savings programs such as insurance sponsorship, PRC/MLR, discounted
pharmaceutical pricing, etc. Ensures program applies pricing discounts and cost saving opportunities aligned
with the Affordable Care Act (ACA), the Indian Health Care Improvement Act (IHCIA), the Indian Self-
Determination and Education Assistance Acts (ISDEAA); and related health care laws applicable to Native
Americans.

Prepares and sends out request for proposal (RFP) for the Third Party Administrator (TPA) contract.
Maintains the contract and works closely with the TPA who processes the patient claims. Works with Broker
to ensure good working relations with TPA.

Negotiate and secure care coordination contracts with specialty medical facilities/providers and local
pharmacies. Ensure PRC staff and contractors process services in an efficient manner and provide quality
customer services. Ensures the Provider Contract List is updated as needed and distributed to appropriate
staff. Implements patient satisfaction systems to measure service delivery outcomes from outside providers.

The position develops and delivers appropriate orientation/training on PRC policy and procedures to
individuals and groups who interface with the PRC program, including but not limited to: PRC staff, FHBC,
patient/clients, community members, primary medical providers, and members of the Managed Care
Committee.

Purchased Referred Care (PRC) Manager

Updates program brochures and resource manual as PRC changes occur. Writes news articles to inform
service population about PRC services and procedures.

Issues letters of denial for non-eligible referrals to PRC and informs patients about appeals and/or patient
concern processes.

Develop and implement a PRC managed care committee. Chairs the Managed Care Committee (MCC).
The MCC reviews, approves, or denies lower-level primary care provider consults to assist PRC effectively
managed referrals and ensure they are medically necessary. The MCC will review patient appeals and may
uphold or overturn a denial of payment based on medical need and compliance with PRC guidelines.

At least once every three years Coordinates with the THHS Quality Improvement Coordinator to develop,
implement, and complete PRC Quality improvement projects. Submits final product to the THHS Quality
Improvement coordinator for potential external AAAHC evaluation.

Writes monthly, quarterly, and annual reports, which contain statistical updates following guidelines set by
THHS Administration. Presents information to the Fort Hall Business Council as assigned.

Participates with the department’s strategic planning processes. Establish long- and short-term program
goals and objectives that include timelines for accomplishment. May establish priority projects, goals, and
objectives using community assessments, program trends, or funding agency requirements. Serves as a
resource person to the Tribal Health Administration in program planning and evaluation utilizing information
identified through conducting ongoing evaluation of program services.

Prepares for and maintains AAAHC Accreditation standards within PRC program. May be interviewed during
a survey (every 3 years). Is a member of the THHS Executive Committee and is directly involved with AAAHC
(Accreditation Association for Ambulatory Health Care) compliance standards and OSHA regulations.

MAINTAINS STRICT CONFICENTIALITY OF ALL PROGRAM INFORMATION INCLUDING RECORDS,
REPORTS, DOCUMENTS, CONVERSATIONS, ETC. A breach of confidentiality will be subject to
appropriate disciplinary action, up to and including termination from employment.

Responsible for modeling high standards of honesty and integrity in all matters relating to employment with
the Shoshone-Bannock Tribes; and, are required as a condition of employment to conduct themselves both
on and off the job in a manner that brings credit to the Tribal Government.

Motivates department personnel and peers toward future goals. Monitors and evaluates program
performance and accomplishments; assesses overall effectiveness and efficiency and provides appropriate
incentives, guidance.

Interfaces with grant agency and Tribal management system personnel to assure programs are managed in
compliance with applicable regulations and Tribal Management System policies and operating procedures
governing Personnel, Finance, Contracting, Administration, Records, Facilities and Property. Take
necessary corrective actions when merited.

Duties and responsibilities will include other activities needed to carry out the THHS department and program
functions.

Demonstrates fully effective to exceptional management performance standards for each evaluation
factor including but not limited to: Quality program planning, reporting, leadership, problem solving,

Purchased Referred Care (PRC) Manager

interpersonal relations, fiscal management, human resource management, team building responsibilities;
and,

• Understands and effectively applies PRC laws, regulations, resolutions, and policies.

• Works as a team leader, displays a high level of effort and commitment to the Shoshone-Bannock Tribes

service population.

• Provides quality services, shows understanding, friendliness, courtesy, cooperation, and politeness to all

job contacts.

• Has a reliable attendance record and is an accountable Manager

• Is pro-active and completes tasks in a timely manner.

• Writes and submits reports in a clear, concise, and timely manner.

• Establishes professional working relationships with all job contacts.

• Projects a professional attitude and appearance.

• Provides quality supervision, management, and direction of program personnel.

• Participates and encourages staff to participate in continuous quality improvement, professional

development, course work, and training opportunities to enhance service delivery and career
development.

• Implementation of program operating policies, procedures, and protocols.

• Ensures compliance with AAAHC standards: including the design, implementation, completion and

evaluation of program Quality Improvement Projects.

• Complete all mandatory THHS required training and quarterly drills.

• Ensures program personnel have complied with the THHS Employee Health Policy and annual

immunization schedule.

• Complies with THHS Policy Manual

• Complies with Tribal Management Systems policies and procedures.

• Maintains a secure workstation that protects patient/client information in compliance with THHS

information security rules of behavior.

CAREER ADVANCEMENTS:

One-step pay increase for successful completion of medical coding course with completion score of 70% or
higher.

One-step pay increase for related CPC National Certification.

QUALIFICATIONS:

The letter of application must demonstrate qualification required to perform the essential duties and
responsibilities defined within this job announcement.

The qualification requirements and compensation assignments are progressive and aligned with the following
levels of education and experience:

Minimum Educational & Experience Qualifications (Grade 13):

A high school diploma or GED with six years (6) years related work experience.

Must have related experience implementing and interpreting federal regulations, program policies and
procedures.

Purchased Referred Care (PRC) Manager

Must have a combination of education and verifiable work experience that demonstrates management
experience with personnel supervision, developing program goals and objectives, administration of contracts,
budgeting, and writing program reports.

Must have current business application computer skills including word, excel, and ability to learn electronic
systems used to process patient information, payroll hours, employee actions, purchasing, pay invoices,
travel, policies, program planning, etc.

Preferred Education & Experience Qualifications (Grade 14-17 DOE Negotiable):

Seeking applicants with successful experience interpreting federal regulations and enforcement of internal
operating policies and procedures.

Experience with the RPMS system is preferred.

Grade 17: A Master’s degree in Health Care Administration, Business Management, or related field of

study from an accredited institution of higher education; and two (2) years management
experience or related experience.

Grade 16: A Bachelor degree in Health Care Administration, Business Management or related field of

study; and four (4) years management experience or related experience.

Grade15: A Bachelor degree in Health Care Administration, Business Management or related field of

study.

Grade 14: A Associate degree from an accredited Health Care program, Business Management or related

field and related experience.

Additional Qualifications:

Must have experience with quality improvement processes and be able to provide examples of such
experience.

Applicants considered for a job offer will receive a pre-employment reference check to verify employment
history demonstrates creditability, dependability, and exceptional management capabilities. The Tribes will
complete a criminal history background check in compliance with job specific requirements. The results must
indicate suitability for employment.

Positions that have regular contact or control of children will receive a background check in compliance with
the Indian Child Protection and Family Violence Prevention Act (25 CFR Part 63). The adjudication results
must be favorable.

Preferred Knowledge, Skills, and Abilities:

Current knowledge of the PRC Program regulations
Knowledge of the Shoshone-Bannock Tribes culture and traditions and/or languages.

Knowledge of the applicable Federal, State, and Tribal laws, statutes rules, regulations pertaining to
health care administration and management.

Purchased Referred Care (PRC) Manager

Knowledge of the Health Information and Portability and Accountability Act (HIPAA).

Qualified Shoshone-Bannock Tribal Member/Indian and Veterans Preference will apply in compliance with
the Shoshone-Bannock Tribes Personnel Policies and Procedures Manual.

IMPORTANT APPLICATION CRITERIA

Instructions: You must turn in all supporting documents to be eligible for this position you are
applying for.

A complete application must be submitted to the Shoshone-Bannock Tribes Human Resource Department,
P.O. Box 306, Fort Hall, Idaho 83203. Applications can be found online at www.sbtribes.com. Applications
can be sent via email to recruitment@sbtribes.com or faxed to 208-478-3950 and are accepted until 5PM on
the closing date.

Submit a copy of all supporting documents to be eligible for the position you are applying for. For example:
Driver’s License, Tribal ID, High School Diploma/GED, Degree or professional credentials, and other
supporting documents that verify required qualifications.

Telephone calls are not accepted in place of an employment application or letter of interest.

Applicants who have a current application on file, please submit a letter of interest for each position in which
you want to be considered for. The letter should address how you meet each qualification.

Preference will be given to Shoshone-Bannock Tribal member applicants who provide a copy of their tribal
enrollment card. Non-enrolled members and other Indian tribal members must provide a Certificate of Indian
Blood (CIB) to receive preference.

Preference points will also be given during the interview process to veterans who provide documentation of
a DD-214.

Applicants being considered for employment or a political appointment must submit to a pre-employment
alcohol and drug screen prior to being hired or appointed. Refusal to take the test will render the applicant
ineligible for employment or political appointment.

The Shoshone-Bannock Tribes will conduct an employment background check on new employees to ensure
suitability for the position applied for.

Purchased Referred Care (PRC) Manager