When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
This position exemplifies Winchester Hospital’s values and commits to making every encounter with our patients, patients’ family, co-workers, physicians and other customers the best that it can be. This role also supports all Highland Management Clinical Program Projects, including the Out-of-IPA Referral Program, the Out-of-IPA Admissions Program, and maintenance of the Highland Management referral database under the direction of the Performance Improvement Coordinator.
Job Description:
Qualifications
Education/Experience Required:
- Associate’s degree or at least 3 years of related work experience.
- At least one year of experience with a healthcare or managed care organization necessary.
- Strong interpersonal, organizational and customer service skills required.
- Microsoft Office and Internet proficiency required. Epic and Access experience preferred.
- Ability to learn other computer programs and use organization’s databases to support activities.
- Knowledge of Medical Terminology required.
- Must have strong oral communication skills.
JOB FUNCTIONS
- Responsible for all aspects of processing out-of-IPA referrals.
- Verifies completeness of Out-of-IPA referral forms received via fax, IPA website, or US mail, contacting Primary Care Physician office staff, if necessary, for additional information or to clarify information.
- Communicates any educational opportunities that are identified to the Highland Management Provider Relations Specialist.
- Researches patient information via internet and Epic such as health plan eligibility, PCP verification, prior referral history, etc.
- Researches physician information such as health plan contract affiliation, NPI number, hospital affiliation, address, etc.
- Responds to phone calls from IPA physicians (PCPs & Specialists) and physician office staff with referral questions requiring research, problem solving, and follow-up. Communicates new information to colleagues as needed.
- Provides education and support to IPA physicians and physician office staff as it relates to the Out-of-IPA Referral Program.
- Promotes and encourages in-IPA specialists and Winchester Hospital services through office staff education and assistance with appointment scheduling, as necessary.
- Collaborates with Performance Improvement Coordinator, IPA Provider Relations Manager, and Health Plan Provider Relations for assistance with referral questions, as necessary.
- Acts as Liaison between Tufts out-of-network physician reviewer and PCP practice for Tufts out-of-network referrals received.
- Contacts Tufts website staff for assistance as needed.
- 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 (via internet or paper referral form) 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-IPA referral information into the Highland Management referral database.
- Prepares patient referral packets for mailing to out-of-IPA specialist.
- Maintains supply of all forms necessary to facilitate referral processing.
- Generates and quality control checks monthly Out-of-IPA Referral Submission report for Performance Improvement Coordinator review, updating the Highland Management referral database, as needed.
- Responsible for mailing quarterly Out-of-IPA Referral Submission Report to each PCP.
- Responsible for maintenance of Highland Management Referral database; updating database with new and terminated PCPs, quality control checks database for consistent and accurate data.
- Identifies enhancement opportunities for referral database and responsible for lead role between Hospital Information Systems personnel to accomplish enhancement goal(s).
- Completes Out-of-IPA Admission tracking form for each out-of-IPA admission from the Health Plan census reports and Tufts Medical Center Admission Notification report. Completes and faxes the admission notification form to the Primary Care Physician.
Responsible for Highland Management clinical program projects including but not limited to:
- Researching and obtaining patient lab & radiology results in Epic and preparing reports for distribution to physicians.
- Researching and obtaining information in physician reports from the IPA reporting consultant-ManagedCare.com and preparing reports for distribution to physicians.
- Updating Physician Performance Profile Report results for physician performance measures.
- HPHC HIT Survey Project.
- Coordinates and organizes complex mailings to IPA physicians, practice managers, nurse practitioners, and physician assistants, including reminder mailings and faxes as applicable.
- Preparing meeting presentation packets.
- Responsible for updating and quality control check of MHQP website database with physician and practice manager information. Liaison to MHQP staff.
- Responsible for updating BCBSMA Physician Reconciliation Report as needed.
- Maintains appropriate internal and external confidentiality to ensure compliance with HIPAA and other regulatory requirements.
Participates in the following:
- Mandatory training requirements as per hospital/unit policies
- Continuing education/in-services to enhance knowledge
- Staff meetings
- Performance improvement initiatives
- HM/IPA website team
- Orientation of new staff, students, and/or volunteers
Pay Range:
$20.00 – $30.00
The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.
