Location: Winchester, MA
Job ID: 166686-1A
Date Posted: Jun 21, 2021
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 System’s mission by assisting the PHO organization facilitate the referrals required to manage the PHO patient's care plans. This position will impact the fiscal success by encouraging in-network referrals. This administrative position will ultimately have an impact on the effectiveness of patients’ plans of care and patient satisfaction by streamlining the referrals to specialists and other resources.
· At least one (1) year of experience in a medical practice or managed care organization in a related role.
· Plus either:
o An Associates Degree and an additional two (2) years of directly relevant experience.
o A Bachelors Degree in a related field
o Four (4) years of experience in a medical experience in a medical practice or managed care organization in a related role with at least two (2) of those years in either referrals or data analysis.
· Experience with Microsoft Office and an EMR system
· Work experience involving data analysis and data presentations.
· Ability to communicate orally and in writing, with empathy
· Excellent communication and customer service skills
· Knowledge of Medical Terminology
· Strong competency in Excel and on the internet.
· Ability to proofread documents and check for accuracy
· 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.
LICENSES, REGISTRATIONS, CERTIFICATIONS: N/A
LIFE SUPPORT CERTIFICATION REQUIRED: N/A
POPULATION SPECIFIC REQUIREMENTS: N/A
OTHER JOB REQUIREMENTS:
Schedule requirements: Generally business hours, however some flexibility with time availability will be required based on business and physician needs
Travel requirements: Occasionally expected to travel to practices and other PHO related locations
Reports to the Manager of Managed Care and Referrals
· Not responsible for supervising the work of others
As part of the WinPHO team, this position:
· Collaborates with the WinPHO team, patients and physicians to streamline the referral process for patients.
· Researches and remains aware of the major health referral requirements and procedures.
· Verifies completeness of referral forms received contacting Primary Care Physician office staff, if necessary, for additional information or to clarify information.
· Researches patient information such as health plan eligibility, PCP verification, prior referral history, etc. via internet and/or in the EMR. When necessary contact the patient.
· Researches physician information such as health plan contract affiliation, NPI number, hospital affiliation, address, etc.
· Responds to phone calls from PHO physicians (PCPs & Specialists) and physician office staff with referral questions requiring research, problem solving, and follow-up. Communicates new information to colleagues as needed.
· Collaborates with Performance Improvement Coordinator, other PHO staff, Practice staff, and Health Plan Provider Relations for assistance with referral questions, as necessary.
· Acts as Liaison between out-of-network physician reviewers and PCP practices for out of-network referrals received.
· Faxes ‘disagree’ notification to Primary Care Physician offices, where applicable. Follows-up on ‘disagree’ referrals with Primary Care Physician offices for final status.
· Completes and processes referral authorization requests received from Primary Care Physician offices.
· Evaluates and assigns Referral Code(s) to each referral.
· Maintains organized, accessible files on referral authorization requests and finalized referrals for cross-reference and documentation.
· Data enters all out-of-network referral information into the PHO referral database.
· Prepares patient referral packets for mailing to out-of-network specialist.
· Maintains supply of all forms necessary to facilitate referral processing.
· Maintains records and performs data analysis to understand leakage and referral usage.
· Creates and maintains a referral database; updating database with new and terminated PCPs, specialists and other resources. Performs quality control checks to ensure consistent and accurate data.
· Generates and quality control checks monthly Out-of-network Referral Submission report for review, updating the PHO team as needed.
· Runs reports on referrals and analyzes usage and out of network referrals.
· Creates scorecards, easy to follow reports and presentations regarding referral usage and leakage issues.
· Analyzes data on a system-wide, by practice, by modality and other data subsets to better enable the team to dissect the data and create effective action plans to reduce out of network usage.
· Contributes to and/or conducts correlation analysis of referral issues implications on quality and financial measures.
· Analyzes data to identify and communicate trends and anomalies. Investigates to better understand the data and/or to assist team members in more comprehensive understanding and/or use of the data.
· Creates custom report to hone in on issues and trends.
· Streamlines the referral process throughout the system:
· Collaborations with PHO team and healthcare payers to write and edit clear policies and procedures related to referrals.
· Provides education and support to PHO physicians and physician office staff as it relates to the Out-of-network referrals in order to promote and encourage the use of PHO affiliated specialists. Meets with practices managers and/or physicians one on one to coach them on how to better utilize in-network resources and streamline the referral process.
· Communicates any educational opportunities that are identified to the supervisor, and at the direction of the supervisor, develops educational materials and instructions and when necessary provides one on one or classroom training on the proper procedures.
· Updates Physician Performance Metrics results for physician performance measures.
· Liaisons with other Winchester Hospital and PHO contacts to optimize the practices’ ability to implement contractual quality indicators and other best practice initiatives.
· Identifies roadblocks to in-network referrals and makes recommendations to help alleviate the issues.
· Identifies enhancement opportunities for referral database. Acts as the primary liaison Hospital Information Systems personnel to accomplish enhancement goal(s).
· Participates in PHO projects and other administrative support including but not limited to:
· Coordinates and organizes complex mailings to physicians, practice managers, nurse practitioners, physician assistants and other as specified, including reminder mailings and faxes as applicable.
· Prepares meeting presentation packets.
· Supports and assists the PHO team as needed to achieve best practice quality care standards for patients.
· Maintains appropriate internal and external confidentiality to ensure compliance with HIPAA and other regulatory requirements.
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.