Patient Revenue Management Organization

Pursue your passion for caring with the Patient Revenue Management Organization, which is the fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions for Duke Health.

General job description:

Inpatient Pre-Service Verification is an integral part of the revenue cycle, responsible for overseeing the verification of patient insurance eligibility, prior authorization, and medical necessity for surgical services and admissions across Duke Health.

This position is responsible for the management of internal/external, clinical/non-clinical staff and processes supporting pre-service verification functions while modeling Duke's values and demonstrating expected behaviors. The scope of prior authorization and medical necessity includes, but is not limited to, inpatient and outpatient surgical services and admissions. The manager is also responsible for the oversight of technical systems supporting automated/real-time authorization (RTA).

Duties and Responsibilities of this Level:

Operational Management 40%

• Drive independent revenue cycle operational decisions to resolve complex issues impacting authorizations, patients, and providers.
• Prepare weekly and monthly reports summarizing operational performance related to service volumes completed, outstanding inventory (work-in-progress), and outcomes of verification related to eligibility/authorization/medical necessity.
• Identify deficiencies in staff performance and inventory backlogs in a timely manner, and take action to address outstanding issues.
• Partner with Patient Account Analysts to monitor authorization and registration denial rates and write-off trends to identify and implement opportunities to improve performance.
• Review and approve write-off requests per policy.
• Work proactively and collaboratively with other PRMO management and DUHS leadership to reduce denial rates and avoidable write-offs through issue identification, research, communication, and process improvement.
• Define criteria and create operational workflows and system workqueues to ensure timely and comprehensive verification of eligibility, authorization, and medical necessity for all surgical services and admissions.
• Monitor operational performance and assign/allocate staff to all system workqueues to ensure appropriate and equitable resource allocation and prioritization of outstanding workload.
• Communicate with organizational customers/stakeholders to proactively identify and manage performance issues.

Technical Expertise 25%

• Develop and maintain a working and effective knowledge of all operational functions, policies, and procedures performed within the department, related to insurance payor requirements for verification of coverage/eligibility, authorization, and medical necessity.
• Develop and maintain a working knowledge of the associated technical logic within the Epic system as well as bolt-on systems supporting eligibility and automated authorizations.
• Develop and maintain working and proficient knowledge of personal computer software required for fulfilling management responsibilities, including:Microsoft Office (Outlook, Excel, Word, PowerPoint, etc.), patient accounting systems, IT systems (Service Now Requests), and HR systems (payroll, I-forms, and API PTO).

Staff Management 25%

• Post, recruit, and hire direct reports, and provide orientation to new hires.
• Provide job-specific training to existing direct reports, and ensure that appropriate training is available and provided to staff within the department.
• Ensure that monthly Overall Effectiveness Rating (OER) scores (productivity and quality) are determined for each employee, and feedback is shared with relevant employees and management.
• Conduct mid-year and year-end performance evaluations, provide appropriate feedback and coaching to direct reports.
• Ensure and monitor online yearly safety and LMS training requirements for staff.
• Identify and implement programs to develop direct reports and associated staff for career development.
• Hold regular team meetings to review performance, share new policy and procedures, and keep employees informed about departmental and PRMO updates.
• Identify and implement opportunities for improvement of staff morale.
• Ensure compliance with all PRMO and DUHS personnel policies.

Policy & Procedure and Internal Controls 5%

• Develop and maintain documentation summarizing workflow processes and operating policy & procedure for all functions handled by the team.
• Review changes to all operational processes with the department director prior to implementation.
• Develop, manage, and monitor internal control performance for all operational processes, and ensure the timely completion of internal control processes by staff on an assigned periodic basis.

Other Managerial Duties 5%

• Prepare and submit for approval an annual budget for the department.
• Review actual vs. budgeted variances on a monthly basis, and provide summary of explanation to director.
• Identify opportunities to reduce or minimize personnel and non-personnel costs.
• Respond to inquiries from PRMO and DUHS leadership, peers, and staff in a timely, accurate, and comprehensive manner (ie: 24-48 hours, depending on circumstances).
• Adhere to all PRMO and DUHS revenue cycle policies and regulations.
• Respect and maintain confidentiality regarding patient/guarantor financial data and patient medical data consistent with HIPAA standards.
• Provide coverage for peer managers in her/his absence.
• Other duties as assigned.

Required Qualifications at this Level

Education:

A bachelor's degree in business administration, accounting, management, healthcare administration, nursing, or other related degree is required. Master's degree preferred.

Experience:

Six years of experience in the healthcare industry or other applicable experience. A master's degree in a related field, such as business or health administration, may be substituted for experience.

Degrees, Licensure, and/or Certification:

Certifications in patient access and/or Epic is preferred.

Knowledge, Skills, and Abilities:

Knowledge of payor requirements related to eligibility, authorization, and medical necessity.

Knowledge of clinical medical terminology, procedures, and diagnosis.

Ability to use analytical and deductive skills to recognize variances in large datasets, draw conclusions, and develop/implement action plans.

Strong oral and written communication skills.

Knowledge of Epic Electronic Health Record is preferred.