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
- HS degree
- 2-3 years of Clinical Experience
- Quality Monitoring and Improvement experience
- Data auditing and analysis experience
- 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.
- Competence with Epic.
- Demonstrated skills in identifying process trends, implementation of improvement activities, and monitoring thereof.
Schedule Requirements: Work hours and/or work days may temporarily or permanently change based on the needs of the organization.
- Reports to Supervisor , Utilization 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
- 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:
- Receives faxed information and inquiries from internal and external sources and reviews for accuracy, completeness, appropriateness, and eligibility for services.
- Communicates with appropriate colleagues regarding issues related to insurance approval.
- Partners with admission/registration departments so that payers are notified of hospitalizations prior to submission of clinical submission.
- Processes, enters, and distributes referral and authorization information to clinicians.
- Supports colleagues in obtaining insurance authorizations as needed.
- 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
- Resolves customer complaints and requests related case management issues.
- Controls special order requisitions to Materials Management.
- Facilitates Process Improvements
- 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.
- 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
40 Hours Weekly
Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve. Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health. Beth Israel Lahey Health Performance Network is a unified joint contracting and population health management organization, jointly governed by participating physicians and hospitals.
Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.