Case Management Operations Specialist

Location: Winchester, MA
Job ID: 160443-1A
Date Posted: Feb 20, 2020
Category: Support

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Job Description

Welcome To

Welcome to Winchester Hospital, part of Beth Israel Lahey Health. Winchester Hospital was the first hospital in Massachusetts to earn Magnet recognition, the American Nurses Association’s highest honor for nursing excellence, three times. It has since received the recognition a fourth time. As the northwest suburban Boston area’s leading provider of comprehensive health care services, the 229-bed facility provides care in general, bariatric and vascular surgery, orthopedics, pediatrics, cardiology, pulmonary medicine, oncology, gastroenterology, rehabilitation, radiation oncology, pain management, obstetrics/gynecology and a Level IIB Special Care Nursery.

 

About the Job

JOB SUMMARY:           

Contributes to the Hospital’s mission by serving a multi-purpose role of managing work queues, auditing  documentation, analyzing data, processing insurance information,  and assisting colleagues in facilitating process improvements – all in an effort to ensure that document integrity is sound and in line with payer expectations, contributing to favorable revenue cycle.  This administrative position will have an impact on provider, patient, and staff satisfaction and on financial success by monitoring processes, contributing to the provision of accurate and high integrity documentation, and streamlined workflows.   

 

QUALIFICATIONS:

Education/Experience

Required:  

·        Bachelors degree in Business, Health Care Administration or other highly relevant field; and 4 years of experience in a health care environment. 

·        HS degree and  8 years of work experience in a comparable position may be substituted for a Bachelors degree.

 Preferred: 

·        Quality Monitoring and Improvement experience

·        Data auditing and analysis experience

Other Skills/Knowledge

Required:

·        Competence in both Google and Microsoft Office products including Excel, Word, 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.

 

Preferred: 

·        Competence with Epic.

·        Demonstrated skills in identifying process trends, implementation of improvement activities, and monitoring thereof.

 

LICENSES, REGISTRATIONS, CERTIFICATIONS:

Required:   N/A

Preferred:

                                    

LIFE SUPPORT CERTIFICATION REQUIRED:  N/A

POPULATION SPECIFIC REQUIREMENTS:  N/A 

OTHER JOB REQUIREMENTS:

On-call Requirement:  N/A

Schedule Requirements:  Work hours and/or work days may temporarily or permanently change based on the needs of the organization. 

Travel Requirements:   N/A

 

REPORTING RELATIONSHIPS:

·        Reports to Manager of Case Management

·        May be responsible for directing the workflow of others to meet the needs of the organization.

·        Not responsible for the supervision of others

As part of the Hospital team, this position is multi-dimensional and intended to be flexible in response to departmental and organizational competing priorities.  Duties may be assigned in either a temporary or permanent capacity as the needs of the department evolve.  This position primarily/regularly:

 

·        Oversees all departmental work schedules for each colleague.  Ensures appropriate coverage and escalates issues to manager.

·        Assists Case Managers with all aspects of utilization review/discharge planning/performance improvement processes.

·        Functions as liaison for all electronic platforms including NaviHealth, Change Healthcare, Epic, etc.

·        Manages all case management work queues by researching and following up on all individual issues as well as identified trends in the data.

·        Partners with LHSS for elements requiring involvement of hospital billing, Admissions, ADT, denial management, and corrections to accounts.

·        Escalates unresolved or concerning issues regarding documentation, quality, billing, denials, or anything else related to departmental operations to the appropriate person for resolution.

·        Contributes to a high integrity, operation by ensuring the documentation is processed in line with organizational and regulatory standards.

·        Audits documentation and analyzes data

o   Manages work queues and reports, reviews for accuracy and analyzes to identify trends and issues.

§  Runs various reports from in-house and government reporting systems. 

§  Audits records for accuracy and addresses discrepancies.

§  Compares data to industry/area norms and previous performance.

§  Highlights trends and concerns to the appropriate parties, utilizing the proper chain of command.  Recommends plans of action and implements as directed.  

.

·        Insurance involvement:

o   Receives faxed information and inquiries from internal and external sources and reviews for accuracy, completeness, appropriateness, and eligibility for services. 

o   Communicates with appropriate colleagues regarding issues related to insurance approval.

o   Partners with admission/registration departments so that payers are notified of hospitalizations prior to submission of clinical submission.

o   Processes, enters, and distributes referral and authorization information to clinicians.

o   Supports colleagues in obtaining insurance authorizations as needed.

o   Identifies potential payment issues with Medicare and other payers and communicates and/or resolves issues as appropriate to minimize denials and payment delays. 

 

·        Patient Experience and Systems

o   Resolves customer complaints and requests related case management issues.

§  Controls special order requisitions to Materials Management.

·        Facilitates Process Improvements

o   Participates in department and hospital performance improvement initiatives intended to improve the efficiency, reduce operational costs, capture appropriate billing, streamline processes and/or improve patient satisfaction and quality.  Makes recommendations through the chain of command to address opportunities for streamlining processes and cost containment.

o   Identifies areas of improvement, working directly with leaders and colleagues to ensure compliance and streamline processes related to meeting CMS, DPH, and TJC standards and regulations.

Shift

Part time, 24 hours.

About Us

Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.

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