PRC Case Management Supervisor

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,…