GENERALSUMMARY/ OVERVIEW STATEMENT
TheQA Reviewer/Analyst, under the direction of the Director, is responsible for identifyingand mitigating risk of denials to the Department and ensuring highest qualityof work by the Admissions Counselors via daily management of Patient AccessEPIC WQs (Patient/Account/Claims); weekly review of the in-house high dollarOntrac accounts; monitoring of DFCI patients in BWH beds; oversight of denialsin conjunction with Department Team Leads and Manager, among otherresponsibilities aimed at improving the financial health of the Departmentoverall. Identify training needs of Department and individual staff members.Track denials for all staff members.
In addition, the QA Reviewer/Anaylst will act as a Department resource, whichmay include assisting in the training of new hires, or the retraining ofexisting hires. Will act as lead for teams, as assigned, which can vary. Willassist Team Leads and Manager in reviewing Ontrac exceptions and tracking KPIand meeting Department expectations, e.g., elective teams days out, urgent teamcompleted post discharge metrics. Will assist Management team in projects asnecessary and assigned.
PRINCIPALDUTIES AND RESPONSIBILITIES
- WorksEpic WQs for Inpatient Accounts Team, looking for discrepancies, makingcorrections, alerting staff of needed authorizations/changes in authorizations.Alerts Management to potential problems
- Tracksstaff metrics for Management
- Actsas lead to teams, as assigned.
- Runsreports, as assigned.
- Actsas resource for training new and/or existing employees.
- Worksprojects related to the Inpatient Accounts Department, as assigned.
- Assistsin the review of staff denials, as assigned.
- Actsas a Subject Matter Expert for the Department, and may be asked to participatein meetings, as necessary.
- Runsand reviews In House High Dollar report and alerts Management to issues andneed for follow up
- Workswith Department Coder for retro coding issues
- MonitorsDFCI cases transferred to BWH from DFCI Team
- Fillsin as Admissions Counselor on at least 3 of the 4 teams in times of extreme lowstaffing. See responsibilities listed below for this role.
- Verifiesand/or collects demographic and financial information on all scheduledvisits. Enters/edits data on-line asneeded, ensuring its accuracy and integrity.
- Contactsinsurance companies, managed care plans and outside agencies to verifyinsurance coverage and benefits. Determines if any pre-admission/pre-visitrequirements exist.
- Compilesand submits clinical information required to obtain preadmission approvalsprecertification. Monitors pendingcases to ensure that approvals are obtained prior to visit.
- Makesappropriate referrals to Patient Financial Services Department.
- Recommendsdelay or deferral for non-emergent cases until financial issues can beresolved.
- Reviewsand follows-up on all emergency and unscreened admissions as soon as possible,but within 24 hours atthe latest, to identify and minimize financial risk to the institution.
- Maintainspatient confidentiality and privacy by accessing patient information only tothe extent necessary to fulfillassigned duties. All patient informationmust be kept private, confidential and secure. All lists, reports, filesand documents must always be properly secured and stored. Interviews and examinations should be conductedin such a manner as to afford the patient reasonable audio and visual privacy.
- Maintainseffective working relationships and communicates regularly with Social Service,Care Coordination andother departments to update and exchange pertinent account information.
- Adheresto Customer Service Standards by demonstrating professionalism, alertness,helpfulness, and receptiveness to all patients, visitors and other staffmembers.
- Employsdiscretion when leaving answering machine messages, or sending faxes.
- Performsspecial projects as assigned.
SKILLS/ABILITIES/ COMPETENCIES REQUIRED
- Bachelor'sdegree or equivalent preferred; highschool diploma required.
- Provenexperience in like setting is acceptable in lieu of educational requirements.
- 3-5years experience in a hospital setting, experience with prior authorizations,billing and reimbursement helpful
- Interpersonalrelationship skills necessary to communicate effectively with patient/family,physicians and their supportstaff, medical staff, nursing staff, other hospital personnel and many externalorganizations and agencies.
- Thetechnical knowledge of specific legal and regulatory requirements and anunderstanding of complex third party and medical assistance polices andprocedures.
- Knowledgeof the hospital information system with emphasis on accounts receivablesprograms.
- Abilityto function independently and prioritize work within established policies.
- Requiresgood judgment, tact, sensitivity and the ability to function in a stressfulenvironment.
- Abilityto maintain confidentiality regarding the patients, their medical histories,demographic and fiscal information,etc.
Varyinglocations. May be at Assembly Row or BWH Main Campus. Primary location BWH MainCampusSUPERVISORY RESPONSIBILITY
Actsas a lead to teams, as assigned. Team sizes can be from 4-7 members, based onthe team.FISCAL RESPONSIBILITY
Promoteinstitutional financial stability based on throughput and data integrity.EEO Statement
Brigham and Women's Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, sexual orientation, protected veteran status, or on the basis of disability.
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