PRC Case Management Supervisor (47829)

The PRC Case Management Supervisor under direct supervision of the PRC Director, is responsible for the clinical leadership, supervision, and operational oversight of the Purchased Referred Care Case Management Program. This position ensures the delivery of comprehensive, patient-centered case management services for patients requiring specialty care, chronic disease management, complex care coordination, transitions of care, and utilization management support. The PRC Case Management Supervisor oversees Registered Nurse Case Managers and is responsible for promoting evidence-based practice, interdisciplinary collaboration, quality improvement, regulatory compliance, and professional development. The supervisor ensures timely coordination of medically necessary services while supporting appropriate utilization of healthcare resources, improving patient outcomes, and reducing unnecessary hospital utilization. The PRC Case Management Supervisor collaborates closely with interdisciplinary team and Quality Management to promote continuity of care and organizational goals. 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.
• Supervises the daily operations of the PRC Case Management Program, ensuring appropriate staffing, workload distribution, case management coverage, and effective delivery of services.
• Recruits, interviews, onboards, trains, mentors, and supports qualified nursing staff; conducts performance evaluations and competency assessments and provides coaching or corrective action as appropriate.
• Provides leadership and clinical oversight to RN Case Managers and serves as a clinical resource to staff and providers regarding case management, care coordination, utilization management, chronic disease management, and regulatory requirements.
• Promotes a Just Culture emphasizing accountability, professionalism, patient-centered customer service, effective communication, teamwork, and continuous improvement.
• Leads staff meetings, educational activities, and ongoing training to support staff competency, regulatory compliance, and departmental goals.
• Provides and oversees case management for patients requiring referred care from pre-admission through discharge and follow-up, including assessment, care planning, coordination of services, reassessment, and continuity of care.
• Refers cases requiring additional medical review or determination to the Chief Medical Officer or other appropriate medical authority.
• Reviews referrals and referred-care encounters for alternate resources and collaborates with PBC, Revenue Cycle, Finance, and other appropriate departments to maximize third-party resources and preserve PRC funds.
• Coordinates with clinical departments, PRC Referral Services, external healthcare organizations, and other stakeholders to facilitate timely referrals, specialty appointments, discharge planning, transitions of care, and continuity of services.
• Collaborates with the Health Systems Supervisor and appropriate staff regarding Catastrophic Health Emergency Fund (CHEF) coordination, alternate resources, reimbursement, and related PRC matters.
• Advocates for patients and families by promoting access to appropriate services, addressing barriers to care, and supporting effective communication throughout the care continuum.
• Conducts chart reviews, documentation audits, and other monitoring activities to ensure accurate, complete, and timely documentation within the electronic health record.
• Uses data, audit findings, and performance measures to identify improvement opportunities, monitor corrective actions, and participate in Root Cause Analyses and performance improvement initiatives.
• Ensures departmental compliance and survey readiness with applicable IHS, CMS, Joint Commission, HIPAA, Tribal, organizational, and other regulatory requirements through ongoing monitoring, education, and corrective action.
• Participates in the development, implementation, evaluation, and revision of departmental policies, procedures, workflows, and performance standards.
• Builds and maintains collaborative relationships with healthcare providers, community organizations, internal departments, and other key stakeholders; serves as a liaison between PRC, clinical departments, and external healthcare organizations.
• Represents the department at leadership meetings, organizational committees, strategic planning activities, conferences, community events, and other meetings as assigned.
• Prepares and presents routine reports regarding case management activities, quality indicators, program performance, and other departmental metrics for the PRC Director and Executive Leadership.
• Maintains confidentiality and adheres to professional, ethical, organizational, departmental, Human Resources, and patient-care standards.
• Demonstrates professionalism, integrity, cultural awareness, and sensitivity in interactions with patients, families, employees, healthcare partners, vendors, and the community.
• Requires completion of tasks or duties assigned by a supervisor.
• 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.
• Maintains regular attendance and punctuality and completes required responsibilities within established timeframes.
• Travels periodically and overnight as required for meetings, training, conferences, and professional development.
• Performs other duties as assigned.

Qualifications

Minimum Qualifications:

Bachelor’s Degree in Nursing (BSN) is required. Master's degree in Nursing (MSN), Healthcare Administration (MHA), Business Administration (MBA), or related healthcare field preferred. Must be licensed as a Registered Nurse in Arizona or a compact state licensure, the District of Columbia, or Puerto Rico. Certification as a Certified Case Manager (CCM) required. Minimum three years clinical experience and one year of experience in case management, discharge planning, or case management with at least two (2) years’ experience of supervisory or leadership experience preferred. Experience with Indian Health Services Purchased Referred Care/Contract Health 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 as 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 managed care and healthcare delivery principles, including utilization review, medical necessity criteria, clinical pathways, practice guidelines, discharge planning, care coordination, and case management.
• Knowledge of federal, state, Tribal, and third-party payer regulations, review requirements, reimbursement requirements, and compliance standards applicable to healthcare services and Purchased/Referred Care (PRC).
• Knowledge of Indian Health Service (IHS), Bureau of Indian Affairs (BIA), Public Law 93-638 Tribal healthcare programs, PRC operations, and applicable legislation affecting PRC programs.
• Knowledge of alternate healthcare resources, Catastrophic Health Emergency Fund (CHEF) processes, reimbursement requirements, and applicable fraud and abuse regulations.
• Knowledge of HIPAA, confidentiality, patient privacy, and requirements for safeguarding sensitive patient, employee, and organizational information.
• Knowledge of cultural competency principles and demographic, socioeconomic, cultural, and linguistic factors that may affect healthcare access and patient outcomes.
• Knowledge of professional ethics, customer service principles, conflict resolution, complaint management, and appropriate workplace conduct.
• Knowledge of duties and responsibilities of the position.
• Skill in critical thinking, strategic planning, decision-making, and analyzing complex problems to identify and implement effective solutions.
• Skill in conducting chart reviews, documentation audits, and other monitoring activities with accuracy and attention to detail.
• Skill in leadership, delegation, staff development, coaching, mentoring, performance management, and team building.
• Skill in process improvement and the use of data to identify trends, evaluate outcomes, develop recommendations, and support organizational decision-making.
• Skill in professional verbal and written communication, including preparing reports, correspondence, presentations, and educational materials.
• Skill in establishing and maintaining effective working relationships with patients, staff, healthcare providers, leadership, referral facilities, vendors, community organizations, and other stakeholders.
• Skill in using Microsoft Office applications, electronic health records, healthcare information systems, databases, payer portals, and other technology required to perform the duties of the position.
• Ability to learn, navigate, and effectively utilize healthcare information systems and databases, including RPMS, EHR/HIE platforms, Cerner, Epic, McKesson, AHCCCS portals, Novitasphere, spreadsheets, and related applications.
• Ability to analyze complex healthcare and operational data and develop reports, dashboards, performance measures, and recommendations for leadership.
• Ability to communicate complex clinical, operational, and regulatory information effectively to staff, multidisciplinary teams, executive leadership, governing bodies, and external healthcare partners.
• Ability to lead and facilitate multidisciplinary meetings, provide staff education, delegate responsibilities, evaluate employee performance, and address sensitive situations with tact and diplomacy.
• Ability to develop, administer, and monitor departmental budgets and effectively manage available resources.
• Ability to establish rapport and work effectively with individuals from diverse cultural, educational, professional, linguistic, and socioeconomic backgrounds.
• Ability to manage multiple priorities, organize workload, meet deadlines, and perform effectively in a fast-paced healthcare environment.
• Ability to exercise sound independent judgment, initiative, and accountability while recognizing situations requiring consultation or escalation.
• Ability to have self-confidence.
• Ability to adapt to changing organizational priorities, healthcare regulations, technology, workflows, and operational requirements and apply constructive feedback to support continuous improvement.
• Ability to demonstrate professionalism, integrity, reliability, accountability, cultural sensitivity, and adherence to WIHCC's Mission, Vision, and Values.

Physical Demands:

While performing the essential functions of this position, the employee is regularly required to walk, sit, use hands and fingers, handle, or feel objects and equipment, reach with hands and arms, and communicate effectively by talking and hearing. 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 50 pounds.
 

Work Environment:

Work is performed in an office setting or outdoor work environment with a moderate noise level.  Work environment may involve exposure to physical risks, such as blood borne pathogens, hazardous chemicals, or operating 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.