Operations Specialist, Case Management, 40hrs Days

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

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.

Job Description:

JOB FUNCTIONS

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.
   

MINIMUM 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 Ex