Supervisor - Managed Care PHO

Location: Winchester, MA
Job ID: 156774-1A
Date Posted: Oct 2, 2019

Job Description

Welcome To

Winchester Hospital is a leading community hospital north of Boston. The hospital offers a full range of medical services including maternity care and a Level IIB Special Care Nursery.  Since 1912, Winchester Hospital has been a trusted pillar of the community and is recognized for outstanding quality and high satisfaction scores. In 2003, we became the first community hospital in Massachusetts to achieve Magnet status -  the industry’s gold standard for nursing excellence.  We were re-accredited for the 4th time in 2018. Our mission To Care. To Heal. To Excel. In Service to Our Community is achieved through streamlined, coordinated and comprehensive high-quality, compassionate care close to home.

 

About the Job

JOB SUMMARY:           

The individual will contribute to the Hospital’s mission by reporting to the Director of Winchester PHO to provide oversight of the referral management department comprised of four Referral Liaison positions, as well as serving as the key contact for managed care data. The individual will have a focus on assessing, interpreting, and analyzing the impact of utilization of services within the Winchester PHO to maximize performance in the managed care contracts that support the BILH Network. The incumbent will work closely with the hospital leadership, physician services, operations, and Accountable Care Unit (ACU) leads to ensure alignment and collaborative efforts to meet system-wide goals.

 

QUALIFICATIONS:

Education/

Required:  

Bachelors degree in healthcare, business administration or a related field

Preferred: 

·        A Masters Degree in Public Health Administration, or Data Analytics.

 

Experience:

·        Five years of experience in health care with a concentration in Referral Management, Revenue Cycle, Performance Improvement, or Managed Care Payor Contracting

·        At least one year of supervisory or team lead experience.

·        In lieu of supervisory experience, incumbent has 5 number of years of progressively responsible positions  in healthcare operations, revenue cycle, or management as a subject matter expert.

·        Minimum one year resolving claims issues with Payer Relations representatives to handle managed care contract implications.

·        Minimum one year of experience  with value-based performance contracts and managed care risk contracts.

 

Other Skills/Knowledge

Required:

·        Understands managed care (HMO/POS/ACO) Referrals

·        Understands claims adjudication, denials and resolution

·        Understands payer agreement and policies.

 

 

 

·        Strong data analytics skills with experience in utilization of registry database programs (i.e. Optum, Athena, EPIC)

·        Strong Microsoft Excel Skills

·        Strong problem-solving skills

·        Strong project management, quantitative and analytical skills

·        Excellent verbal presentation skills as well as ability to write in a clear and concise manner

·        Possesses strong influencing and relationship-building skills.  Ability in communicating effectively

·        Ability to facilitate and to work within dynamic teams as well as to work independently

·        Results oriented, proactive and self-directed; able to work autonomously

·        Detailed knowledge of Microsoft Office products, Excel, Access and PowerPoint.

·        For safety and quality reasons, must be able to read, write and communicate effectively in English with patients, visitors and fellow members of the hospital team.

·        Ability to supervise the work of others.

 

LICENSES, REGISTRATIONS, CERTIFICATIONS:  N/A                                    

LIFE SUPPORT CERTIFICATION REQUIRED:  N/A

POPULATION SPECIFIC REQUIREMENTS:

 

OTHER JOB REQUIREMENTS:

Professional Commitment Requirements:  Keep abreast of developments in the field and/or licensure through continuing education, participation in professional organizations or a combination of both.

 

On-call Requirement:  n/a

 

Schedule Requirements:  Generally business hours but hours may fluctuate based on business needs

Travel Requirements:   Minimal travel required, but some appointments may be required within the Winchester Hospital/Lahey Health community and organization.

 

REPORTING RELATIONSHIPS:

·        Reports to the Director of Winchester PHO

·        Responsible for supervising the work of four Referral Liaison employees in the Winchester PHO Central Referrals Department.

  

SECTION 2: PROMISE COMMITMENT

 

When patients enter Winchester Hospital, they are entrusting us with a responsibility that is otherwise normally their own--the responsibility for their health, well-being, and often, their lives. To honor that trust, all Winchester Hospital employees are expected to demonstrate the PROMISE behaviors of Winchester Hospital in every encounter with patients, coworkers, and the community. PROMISE is an acronym for the following:

 

Promoting Teamwork

Respect

Ownership

Maintaining a Positive Attitude

Initiative

Safety and Quality

Empathy

 

All Winchester Hospital employees are expected to exemplify the PROMISE behaviors

 

SECTION 3: COMPLIANCE COMMITMENT

Winchester Hospital maintains a Compliance Program to ensure that employees comply with all laws, regulations and Joint Commission and other licensure and accreditation standards that apply to our business.  The Code of Business Conduct is a vital part of the Compliance Program.  Employees must be familiar with the Compliance Program and Code of Business Conduct and must comply with their requirements, and the requirements of any other laws and regulations, policies and procedures affecting the performance of their job.  If applicable, employees are expected to comply with standards of conduct outlined by the oversight organization(s) of their profession.

 

SECTION 4: JOB FUNCTIONS

Consistent with the PROMISE principles and inherent in a hospital environment, employees must be flexible in meeting patients’ and the Hospital’s needs. While the list below describes the primary functions of this job, all employees at Winchester Hospital need to recognize that an essential element of their job is the ability to respond to unanticipated and/or changing situations.  This may result in assuming responsibilities or tasks, which are not on this list.

 

As part of the Physician Services and PHO team, this position:

 

·        Creates reporting dashboards for monitoring staff productivity, analyzing referral order patterns and utilization, and building ad-hoc reports as needed.

·        Participates in the hiring process.

  • Supervises referral department staff who have the responsibility to communicate with patients, physician, and insurance companies and to track referral progress. Ensures tracking of referral progress is accurate and timely.

  •         Responsible for ensuring department goals are met, and tracking departmental progress, including staff productivity.

·        Responsible for overseeing, coaching, training, and monitoring the employee's duties.

·        Responsible for monitoring employee achievements and any areas of needed improvement; to offer constructive feedback; to encourage and develop plans for employee development and growth.

·        Ability to implement and follow through on new programs to promote Winchester Hospital’s Local Care Initiative.

  • Analyze reports to elicit insight into potential needs for improvement in processes.

  • Reports to stakeholders, both within the WinPHO and external to the WinPHO on referral progress and communicates needs for additional resources, with supporting documentation, to senior management.

  • Escalates to leadership any persistent obstacles to the referral process that have the potential to hinder progress.

  • Acts as a content expert for all risk bearing managed care contracts and acts as payors’ point-of-first-contact for WinPHO Physician Services

  • Participates in cross-organizational contracting teams, providing data analysis assistance as required..

  • Meets regularly with WinPHO staff and leaders to discuss deliverables, new contracts/benefit plans, payment methodologies, standard reports, etc.  Communicates this information to Physician Services and WPA staff as appropriate.  Communicates, educates, and updates the Physician Services leaders and practice staff on LCPN network level reports, changes to managed care contracts, payor issues, and process updates.

  • Implements strategies to improve utilization and efficiency. Conducts analyses for plan performance, using Managed Care Department analysis standards.

  • Monitors and reports on aspects of WPA-provider participation in WinPHO and WPA payor incentive plans.

  • Provides overviews of plans.  Develops tools to measure plans.  Reports outcomes to all interested parties.  Assist practices in implementation of any tools developed for ambulatory referral management, and managed care utilization

  • Actively monitors and keeps pertinent parties informed regarding state and federal government healthcare programs, including but not limited to changes in payment methodologies.  

  • Analyzes data and develops detailed assumptions used in revenue and expense budgets, cash flow analysis, and ROIs.  Attends physician meetings in order to obtain necessary data to complete development and uses benchmarking to validate results.

  • Trains other department staff in functional area of expertise as assigned by Director

  • Produces monthly financial and statistical analysis and reports based on contractual arrangements. Identifies trends, highlights anomalies and calculates repercussions. 

  • Develops recommendations for improvement to department reports and reference materials. Produces and maintains resource and reference materials to be utilized both intra-departmentally and externally within the Lahey Health System.  

  • Provides managed care related support to other departments with reports, analysis and troubleshooting.

  • Conducts ad-hoc data analyses to support practice development and operations. Completes department special analytical projects as assigned by Director.

  • Investigates and resolves discrepancies discovered as part of the analytic processes.

  • Intakes, tracks and resolves reporting issues that arise from various entities including medical groups, contracted providers and health plans.

  • Provides analytics and report running assistance in the analysis and resolution of global billing and billing related issues and projects, that are result of referral or payer authorizations.

Shift

Full Time, 40 Hours.

About Us

The Lahey Model of Care—right care, right time, right place—is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.