Chart Utilization Review Jobs in Raleigh, NC (NOW HIRING)

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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.

REVENUE INTEGRITY ANALYST - MEDICAL NECESSITY DENIALS (REMOTE POSITION)

General Description of the Job Class:

• Reviews accounts and complete medical records to assess accurate patient class, utilization review outcomes, medical necessity/level of care, etc. in support of overturning insurance denials.
• Initiates actions to obtain appropriate insurance adjudication decisions and/or resolve customer inquiries, including but not limited to completing appeals, working with other internal departments, contacting the payer, etc.
• Exercises independent decisions using analytical and problem-solving skills.

Appeal Review/Support 

• Reviews records for medical necessity, accurate patient class, physician orders, authorizations, level of care, etc. to determine course of action to overturn insurance carrier denial or resolve customer service inquiries
• Review chart and medical policy on denied accounts, determine appeal potential.
• Utilize Interqual and/or Milliman criteria to support accurate denial adjudication.
• Collaborate with Pre-Registration, Coding, Billing, UM, etc. to affect positive denial resolution
• Prepare appeal letters and documentation packets to facilitate overturned denial decisions.
• Provide any needed documentation to justify appeals, including but not limited to letters of medical necessity, case briefs outlining disposition reversal, NCCN/FDA/CMS guidelines, peer-reviewed journal references, etc.
• Submit write-off requests per policy.
• Provide formal and informal education and feedback with other healthcare teams, revenue cycle, providers, etc. to improve collections, reduce accounts receivable, reduce denial rates, and reduce avoidable write-offs through issue identification, research, communication, and process improvement.
• Acts as a consultant/liaison to other PRMO teams when additional information or documentation is needed to resolve denied accounts.
• Assist with retroactive authorizations.

 General

• Validate accurate payer authorizations, review CPT, ICD-10, PCS, and HCPCS coding on denied claim, review billing accuracy.
• Review and complete Customer Service requests to ensure services performed were charged/captured accurately.
• Clinical and health care financial resources to PRMO and broader health system membership.
• Medical Policy liaison for hospital, PDC and PRMO staff including physicians, clinical nurses, patient resource managers, clinic staff, etc.
• Contributes to a positive working environment and performs other duties as assigned/directed to enhance overall efforts for Duke Medicine.

Technical Expertise

• Develop and maintain a working and effective knowledge of all functions performed by team.
• Develop and maintain a working knowledge of relevant payor billing requirements, medical policies, and reimbursement regulations.
• Develop and maintain a working knowledge of all Maestro Care and ancillary systems utilized by teams.
• Develop and maintain complete understanding of all operational policies and procedures relevant to team.
• Develop and maintain working and proficient knowledge of personal computer software required for fulfilling responsibilities, including  Excel, Word, PowerPoint, Payroll software, Payer Portals, reference sites i.e. UpToDate, NCCN, etc.

Required Qualifications at this level:
 

Education: Bachelors degree required.  Clinical background and/or coding experience are strongly preferred.

Experience: Work requires a minimum of 5+ years of healthcare experience, including appeals experience, payer experience, clinical, and or coding experience, etc.

Knowledge, Skills, and Abilities:

• Experience in revenue cycle with a concentration in accounts receivable and denials.
• Excellent communication skills, oral and written.
• Management experience.
• Ability to systematically analyze problems, draw relevant conclusions, and devise appropriate course of action.
• Ability to analyze data, perform multiple tasks, and work independently.
• Must be able to develop and maintain professional, service-oriented working relationships with senior leadership, patients, physicians, co-workers and employees.
• Ability to work in a fast-paced environment, with focus on team building.
• Experience with supervising staff both onsite and remotely.
• Experience with billing and collections; professional and hospital.

Job Code: 00005058 REVENUE INTEGRITY ANALYST
Job Level: F2

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.