Manager Medical Bill Reviewer Jobs in Raleigh, NC

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About Duke Regional Hospital
Pursue your passion for caring with Duke Regional Hospital in Durham, North Carolina. With 388 beds it is the second largest of Duke Health's four hospitals and offers a comprehensive range ofmedical, surgical, and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services.
Job Summary
Under the supervision of the Hospital Manager of Medical Staff Services/DUHS CVO, the Medical Staff Services Coordinator is responsible for coordination of aspects of DUHS Medical Staff Services office by providing essential verification and quality control functions to support DUHS's goals for credentialing and privileging health care providers while ensuring adherence to legal, regulatory, and delegated requirements. Assignments are planned and executed with considerable independence in compliance with established policies and procedures, bylaws, regulations and laws.
Work Performed
Organizing and directing of a comprehensive and specialized credentialing program to assure continued accreditation compliance by the Joint Commission, NCQA, and AAAHC, as well as any other regulatory organizations. Interpretation, explanation and following all regulatory guidelines, including medical staff bylaws, fair hearing plan, rules and regulations and policies. Maintaining accuracy in the Credentialing database to identify (and disseminate to others), medical staff members and their clinical privileges; prepares and maintains other related records and reports. Responsible for the accuracy andintegrity of the credentialing and privileging database system and for data entry performed in the medical staff office. Receives application/reappointment application from the CVO, oversees the completion of the credentialing process for medical, professional, and advanced practice professional staff and granting of clinical privileges/scopes practice for the DUHS Medical Staff. Coordinating, monitoring and maintaining the credentialing and re- credentialing process. For reappointment applications, thisincludes gathering of additional data for incorporation into hospital-specific processes (i.e., QI elements, FPPE/OPPE process, etc.) and evaluation/analysis of confidential healthcare provider credentials for the initial appointment and reappointment processes prior to presentation for the Department Chair, Division Chief, and Credentials Committee review and action. Works with medical staff leadership and hospital clinical staff for the approval and ongoing review of credentialed practitioners. Monitoring and revising credentialing and privileging/scope of practice forms as needed. Ensures maintenance of medical staff, advanced practice professional staff, and professional staff files. Scheduling and supporting (prepares agenda, attends and prepares minutes) the Credentials Committee. Provides support to the Credentials Committee chair as needed. May participate on other Hospital committees as requested. Uses discretion to escalate identified red flags to the Manager, Medical Staff Services/CVO Office. Communicating medical staff information to appropriate departments; including approval notices to the provider, and other entities (if applicable). In addition, prepares reports to the respective boards to comply with their deadlines. Demonstrates effective leadership skills and coordination of intra- department activities and inter-department integration. Assures necessary revisions are communicated with the Manager, Medical Staff Services/CVO Office for the ongoing development and implementation of policies and procedures that guide and support the provision of services. May develop and facilitate the medical staff orientation, as well as other on-boarding activities, as requested by the Manager, Medical Staff Services/CVO Office. Perform other related duties incidental to the work described herein.
Knowledge, Skills and Abilities
N/A
Level Characteristics
N/A
Minimum Qualifications
Education
Work requires analytical, communications and organizational skills generally acquired through completion of a bachelor's degree program. In lieu of bachelor's degree, four years relevant experience in Managed Care or Medical Staff Credentialing/Privileging (in addition to the experience requirement for the role)
Experience
One year of experience in a Medical Staff/Managed Care credentialing office
Degrees, Licensures, Certifications
Certification by NAMSS (CPMSM or CPCS) strongly preferred
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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.