EH - Operations Specialist Case Management at Exeter Hospital – Exeter, New Hampshire

Contributes to the mission of Exeter Hospital and supports the Case Management department by assisting with work queues, auditing documentation, reporting and analyzing data, training staff, processing insurance information and assisting colleagues in facilitating process improvements. Ensure that documentation and processes are in line with payer and post‑acute facility expectations contributing to.

Requirements:

• 3 to 5 years Directly related experience in Medical Setting
• Bachelors Degree
• Strong analytical skills
• EMR/Practice Mgmt software
• Quality monitoring and improvement experience
• Data auditing and analysis experience
• Competence in both Google and Microsoft Office products

Responsibilities:

1. Assists Case Management staff (Utilization Review, Case Management, and Social Work) with all aspects of discharge planning, utilization review and performance improvement processes. Provides varied administrative support to the UR/CM/SW teams and CM leadership. Assists with managing work queues for CM/IUR/SW as needed
2. Manages Case Management department reporting for Utilization Review, Case Management, and Social Work. Runs various reports from in‑house and government reporting systems.
3. Audits reporting for accuracy and analyzes data to identify trends and issues. Compares data to industry/area norms and previous hospital/system performance.
4. Highlights trends/issues/concerns with reporting and escalates to the appropriate parties, utilizing the chain of command. Recommends and participates in planning action steps and assists with implementation as needed.
5. Functions as liaison for electronic platforms used by the Case Management department including but not limited to Epic, Careport, and Interqual. Assists with developing standard operating procedures and trains staff as needed.
6. Audits documentation for CM/UR including but not limited to Medicare notices. Escalates unresolved or concerning issues regarding documentation, quality, billing, or anything else related to department operations.
7. Receives faxed information and inquires from internal and external sources and reviews for accuracy, completeness, appropriateness, and eligibility for services.
8. Communicates with appropriate colleagues regarding insurance authorizations/denials. Processes, enters, and distributes authorization information to clinicians. Identifies potential payment issues and resolves issues as appropriate. Assists with denial and appeal management and partners with patient access and hospital billing related to accounts.
9. Resolves and/or escalates (as appropriate) customer requests/ complaints regarding case management issues. Manages supplies and ordering of materials for the Case Management department.
10. Participates in department and hospital performance improvement initiatives to improve efficiency, reduce operatonal costs, capture appropriate billing, and/or improve patient satisfaction/quality. Makes recommendations through the chain of command to address opportunities to streamline processes and contribute to cost containment.