Prior Authorization Trainer/QA Reviewer - Inpatient Accounts - Hybrid schedule

QA Reviewer/Analyst

General Summary/Overview Statement

The QA Reviewer/Analyst, under the direction of the Director, is responsible for identifying and mitigating risk of denials to the Department and ensuring highest quality of work by the Admissions Counselors via daily management of Patient Access EPIC WQs (Patient/Account/Claims); weekly review of the in-house high dollar Ontrac accounts; monitoring of DFCI patients in BWH beds; oversight of denials in conjunction with Department Team Leads and Manager, among other responsibilities aimed at improving the financial health of the Department overall. Identify training needs of Department and individual staff members. Track denials for all staff members.

In addition, the QA Reviewer/Analyst will act as a Department resource, which may include assisting in the training of new hires, or the retraining of existing hires. Will act as lead for teams, as assigned, which can vary. Will assist Team Leads and Manager in reviewing Ontrac exceptions and tracking KPI and meeting Department expectations, e.g., elective teams days out, urgent team completed post discharge metrics. Will assist Management team in projects as necessary and assigned.

Principal Duties and Responsibilities

• Works Epic WQs for Inpatient Accounts Team, looking for discrepancies, making corrections, alerting staff of needed authorizations/changes in authorizations. Alerts Management to potential problems
• Tracks staff metrics for Management
• Acts as lead to teams, as assigned.
• Runs reports, as assigned.
• Acts as resource for training new and/or existing employees.
• Works projects related to the Inpatient Accounts Department, as assigned.
• Assists in the review of staff denials, as assigned.
• Acts as a Subject Matter Expert for the Department, and may be asked to participate in meetings, as necessary.
• Runs and reviews In House High Dollar report and alerts Management to issues and need for follow up
• Works with Department Coder for retro coding issues
• Monitors DFCI cases transferred to BWH from DFCI Team
• Fills in as Admissions Counselor on at least 3 of the 4 teams in times of extreme low staffing. See responsibilities listed below for this role.

Admissions Counselor Responsibilities

• Verifies and/or collects demographic and financial information on all scheduled visits. Enters/edits data on-line as needed, ensuring its accuracy and integrity.
• Contacts insurance companies, managed care plans and outside agencies to verify insurance coverage and benefits. Determines if any pre-admission/pre-visit requirements exist.
• Compiles and submits clinical information required to obtain preadmission approvals precertification. Monitors pending cases to ensure that approvals are obtained prior to visit.
• Makes appropriate referrals to Patient Financial Services Department.
• Recommends delay or deferral for non-emergent cases until financial issues can be resolved.
• Reviews and follows-up on all emergency and unscreened admissions as soon as possible, but within 24 hours at the latest, to identify and minimize financial risk to the institution.
• Maintains patient confidentiality and privacy by accessing patient information only to the extent necessary to fulfill assigned duties. All patient information must be kept private, confidential and secure. All lists, reports, files and documents must always be properly secured and stored. Interviews and examinations should be conducted in such a manner as to afford the patient reasonable audio and visual privacy.
• Maintains effective working relationships and communicates regularly with Social Service, Care Coordination and other departments to update and exchange pertinent account information.
• Adheres to Customer Service Standards by demonstrating professionalism, alertness, helpfulness, and receptiveness to all patients, visitors and other staff members.
• Employs discretion when leaving answering machine messages, or sending faxes.
• Performs special projects as assigned.

Qualifications

• Bachelor's degree or equivalent preferred; high school diploma required.
• Proven experience in like setting is acceptable in lieu of educational requirements.
• 3-5 years experience in a hospital setting, experience with prior authorizations, billing and reimbursement helpful

Skills/Abilities/Competencies Required

• Interpersonal relationship skills necessary to communicate effectively with patient/family, physicians and their support staff, medical staff, nursing staff, other hospital personnel and many external organizations and agencies.
• The technical knowledge of specific legal and regulatory requirements and an understanding of complex third party and medical assistance polices and procedures.
• Knowledge of the hospital information system with emphasis on accounts receivables programs.
• Ability to function independently and prioritize work within established policies.
• Requires good judgment, tact, sensitivity and the ability to function in a stressful environment.
• Ability to maintain confidentiality regarding the patients, their medical histories, demographic and fiscal information, etc.

Working Conditions

Varying locations. May be at Assembly Row or BWH Main Campus. Primary location BWH Main Campus

Supervisory Responsibility

Acts as a lead to teams, as assigned. Team sizes can be from 4-7 members, based on the team.

Fiscal Responsibility

Promote institutional financial stability based on throughput and data integrity.